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Provider Policies Library | Helpful Resources

Please note that the current policy list is not exhaustive, but rather a collection of policies that providers have expressed an interest in viewing. Amendments, modifications, supplements to these posted policies and/or additional policies may be posted in the near future. If you have any questions regarding these policies, please contact your Provider Relations Representative.



Clinical Policies


Clinical Documents (A-Z)
Clinical Policy: Allogeneic SCT (Adults)
  • Reference Number: CP.FC.31
  • PDF Publish Date: 6/1/2023

    Clinical Policy: Allogeneic SCT (Pediatric)
    • Reference Number: CP.FC.32
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Autologous SCT (Adults)
    • Reference Number: CP.FC.30
    • PDF Publish Date: 3/1/2024

    Clinical Policy: Autologous SCT (Pediatric)
    • Reference Number: CP.FC.33
    • PDF Publish Date: 3/1/2024

    Clinical Policy: Bone-Anchored Hearing Aid
    • Reference Number: CP.MP.93
    • PDF Publish Date: 6/1/2023

    Clinical Policy: Carpal Tunnel Syndrome Injections
    • Reference Number: CP.FC.42
    • PDF Publish Date: 7/1/2023

    Clinical Policy: Caudal or Interlaminar ESI
    • Reference Number: CP.MP.164
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Clinical Policy Committee
    • Reference Number: CP.CPC.01
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Clinical Policy Web Posting
    • Reference Number: CP.CPC.02
    • PDF Publish Date:10/1/2023

    Clinical Policy: Clinical and Preventive Health Guidelines
    • Reference Number: CP.FC.43
    • PDF Publish Date: 10/1/2023

    Clinical Policy: Clinical Trials
    • Reference Number: CP.MP.94
    • PDF Publish Date: 6/1/2023

    Clinical Policy: Cochlear Implant Replacements
    • Reference Number: CP.MP.14
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Cosmetic and Reconstructive Procedures
    • Reference Number: CP.MP.31
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Denial of Medicaid Non-Covered Benefits
    • Reference Number: CP.FC.01
    • PDF Publish Date: 4/1/2024

    Clinical Policy: Dental Anesthesia and Facility Services
    • Reference Number: CP.FC.02
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Diaphragmatic Phrenic Nerve Stimulation
    • Reference Number: CP.MP.203
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Discography
    • Reference Number: CP.MP.115
    • PDF Publish Date: 6/1/2023

    Clinical Policy: Donor Lymphocyte Infusion
    • Reference Number: CP.MP.101
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Donor Lymphocyte Infusion (Medicare)
    • Reference Number: MC.CP.MP.101
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Durable Medical Equipment (DME), Orthotics & Prosthetics
    • Reference Number: CP.FC.06
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Electric Tumor Treating Fields (Optune)
    • Reference Number: CP.MP.145
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Experimental Technologies
    • Reference Number: CP.MP.36
    • PDF Publish Date: 4/1/2024

    Clinical Policy: Facet Joint Interventions
    • Reference Number: CP.FC.18
    • PDF Publish Date: 12/1/2023

    Clinical Policy: Facility-Based Sleep Studies for Obstructive Sleep Apnea
    • Reference Number: MC.CP.MP.248
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Fecal Incontinence Treatments
    • Reference Number: CP.MP.137
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Fertility Preservation
    • Reference Number: CP.FC.15
    • PDF Publish Date: 12/1/2023

    Clinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations
    • Reference Number: CP.MP.129
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Gastric Electrical Stimulation
    • Reference Number: CP.MP.40
    • PDF Publish Date: 3/1/2023

    Clinical Policy: Genetic Testing
    • Reference Number: CP.FC.49
    • PDF Publish Date: 4/1/2024

    Clinical Policy: Heart-Lung Transplant
    • Reference Number: CP.MP.132
    • PDF Publish Date: 3/1/2023

    Clinical Policy: Home Births
    • Reference Number: CP.FC.21
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Home Health Criteria for Prenatal and Postpartum Nursing Visits & Home Health Aide Services
    • Reference Number: CP.FC.04
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
    • Reference Number: CP.MP.180
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Implantable Wireless PAP Monitoring
    • Reference Number: CP.MP.160
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Implantable Wireless PAP Monitoring (Medicare)
    • Reference Number: MC.CP.MP.160
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Injections for Morton’s Neuroma
    • Reference Number: CP.FC.26
    • PDF Publish Date: 12/1/2023

    Clinical Policy: Intradiscal Steroid Injections for Pain Management
    • Reference Number: CP.MP.167
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Intestinal and Multivisceral Transplant
    • Reference Number: CP.MP.58
    • PDF Publish Date: 5/1/2023

    Clinical Policy: Keratoplasty
    • Reference Number: CP.VP.36
    • PDF Publish Date: 5/1/2023

    Clinical Policy: Laser Therapy for Skin Conditions
    • Reference Number: CP.MP.123
    • PDF Publish Date: 3/1/2023

    Clinical Policy: Liposuction for Lipedema
    • Reference Number: CP.MP.244
    • PDF Publish Date: 5/1/2023

    Clinical Policy: Lung Transplantation
    • Reference Number: CP.MP.57
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Lung Transplantation (Medicare)
    • Reference Number: MC.CP.MP.57
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Lysis of Epidural Lesions
    • Reference Number: CP.MP.116
    • PDF Publish Date: 5/1/2023

    Clinical Policy: Mechanical Stretching Devices
    • Reference Number: CP.MP.144
    • PDF Publish Date: 12/1/2023

    Clinical Policy: Medical Necessity Criteria
    • Reference Number: CP.FC.05
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Multiple Sleep Latency Testing
    • Reference Number: CP.MP.24
    • PDF Publish Date: 4/1/2023

    Clinical Policy: Nasal Valve Repair Investigational Procedures
    • Reference Number: CP.FC.50
    • PDF Publish Date: 10/1/2023

    Clinical Policy: Nerve Blocks for Pain Management
    • Reference Number: CP.MP.170
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Neuropsychological, Psychological, and Developmental Testing
    • Reference Number: CP.FC.BH.301.04
    • PDF Publish Date: 4/1/2024

    Clinical Policy: Nonmyeloablative Allogeneic SCT
    • Reference Number: CP.MP.141
    • PDF Publish Date: 3/1/2023

    Clinical Policy: Orthognathic Surgery
    • Reference Number: CP.MP.202
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Out-of-Network
    • Reference Number: CP.FC.20
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Outpatient Testing for DOA
    • Reference Number: CP.FC.17
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Ovulation Induction and Infertility
    • Reference Number: CP.FC.14
    • PDF Publish Date: 12/1/2023

    Clinical Policy: Pancreas Transplantation
    • Reference Number: CP.MP.102
    • PDF Publish Date: 10/1/2023

    Clinical Policy: Panniculectomy
    • Reference Number: CP.MP.109
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Pasteurized Donor Human Milk
    • Reference Number: CP.FC.36
    • PDF Publish Date: 4/1/2024

    Clinical Policy: Pediatric Heart Transplant
    • Reference Number: CP.MP.138
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Pediatric Kidney Transplant
    • Reference Number: CP.MP.246
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Pediatric Kidney Transplant (Medicare)
    • Reference Number: MC.CP.MP.246
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Pediatric Liver Transplant
    • Reference Number: CP.MP.120
    • PDF Publish Date: 3/1/2023

    Clinical Policy: Pediatric Oral Function Therapy
    • Reference Number: CP.MP.188
    • PDF Publish Date: 5/1/2023

    Clinical Policy: Penile Prosthesis Implantation
    • Reference Number: CP.FC.44
    • PDF Publish Date: 6/1/2023

    Clinical Policy: Percutaneous LAAD Stroke Prevention
    • Reference Number: CP.MP.147
    • PDF Publish Date: 7/1/2022

    Clinical Policy: PFO Closure Devices
    • Reference Number: CP.MP.151
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Polysomnography (PSG)
    • Reference Number: CP.FC.22
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Posterior Tibial Nerve Stimulation for-Voiding Dysfunction
    • Reference Number: CP.MP.133
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery
    • Reference Number: CP.MP.51
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Repeat Bariatric Surgery
    • Reference Number: CP.FC.24
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Sacroiliac Joint Interventions
    • Reference Number: CP.MP.166
    • PDF Publish Date: 3/1/2024

    Clinical Policy: Sclerotherapy for Varicose Veins
    • Reference Number: CP.MP.146
    • PDF Publish Date: 10/1/2023

    Clinical Policy: Selective Dorsal Rhizotomy for Spasticity
    • Reference Number: CP.MP.174
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Services not on Fee Schedule
    • Reference Number: CP.FC.41
    • PDF Publish Date: 2/1/2023

    Clinical Policy: Short Inpatient Hospital Stay (HBX)
    • Reference Number: CP.FC.28
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Short Inpatient Hospital Stay (Medicare)
    • Reference Number: MC.CP.FC.182
    • PDF Publish Date: 12/1/2023

    Clinical Policy: Sickle Cell Anemia and β-Thalassemia Cell Transplant
    • Reference Number: CP.MP.108
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Sickle Cell Anemia and β-Thalassemia Cell Transplant (Medicare)
    • Reference Number: MC.CP.MP.108
    • PDF Publish Date: 2/1/2024

    Clinical Policy: Skilled Nursing Facility Leveling
    • Reference Number: CP.FC.47
    • PDF Publish Date: 4/1/2023

    Clinical Policy: Skin Substitutes Policy
    • Reference Number: CP.FC.34
    • PDF Publish Date: 8/1/2023

    Clinical Policy: State CP Process
    • Reference Number: CP.FC.40
    • PDF Publish Date: 12/1/2023

    Clinical Policy: Tandem Transplant
    • Reference Number: CP.MP.162
    • PDF Publish Date: 3/1/2023

    Clinical Policy: Tendon Injection
    • Reference Number: CP.FC.27
    • PDF Publish Date: 1/1/2024

    Clinical Policy: Therapeutic Utilization of Inhaled Nitric Oxide
    • Reference Number: CP.MP.87
    • PDF Publish Date: 4/1/2023

    Clinical Policy: Thyroid Nodule Genetic Testing
    • Reference Number: CP.FC.35
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Total Artificial Heart
    • Reference Number: CP.MP.127
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Transfer Policy
    • Reference Number: CP.FC.03
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Transforaminal Epidural Injections
    • Reference Number: CP.MP.165
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Transplant Service Documentation Requirements
    • Reference Number: CP.MP.247
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Trigger Point Injections
    • Reference Number: CP.MP.169
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Urinary Incontinence Devices and Treatments
    • Reference Number: CP.MP.142
    • PDF Publish Date: 11/1/2023

    Clinical Policy: Vagus Nerve Stimulation
    • Reference Number: CP.MP.12
    • PDF Publish Date: 8/1/2023

    Clinical Policy: Ventricular Assist Devices
    • Reference Number: CP.MP.46
    • PDF Publish Date: 3/1/2024

    Clinical Policy: Video EEG Monitoring
    • Reference Number: CP.MP.177
    • PDF Publish Date: 2/1/2022

    Clinical Policy: Wireless Motility Capsule
    • Reference Number: CP.MP.143
    • PDF Publish Date: 10/1/2023


    Payment Policies


    Payment Documents (A-Z)
    Payment Policy: 14 Day Readmission (Medicaid)
    • Reference Number: FC.PP.003
    • PDF Publish Date: 11/1/2022

    Payment Policy: 25-hydroxyvitamin D Testing in Children and Adolescents
    • Reference Number: FC.PP.027
    • PDF Publish Date: 10/1/2023

    Payment Policy: 30 Day Readmission (Medicare)
    • Reference Number: FC.PP.004
    • PDF Publish Date: 2/1/2023

    Payment Policy: Allergy Testing and Therapy
    • Reference Number: FC.PP.026
    • PDF Publish Date: 10/1/2023

    Payment Policy: Bronchial Thermoplasty
    • Reference Number: FC.PP.017
    • PDF Publish Date: 4/1/2023

    Payment Policy: Claim Validation of Modifier 25
    • Reference Number: FC.PP.001
    • PDF Publish Date: 11/1/2022

    Payment Policy: Claim Validation of Modifier 59
    • Reference Number: FC.PP.002
    • PDF Publish Date: 11/1/2022

    Payment Policy: CMS Correct Coding Initiative
    • Reference Number: FC.PP.020
    • PDF Publish Date: 11/15/2022

    Payment Policy: Digital EEG Spike Analysis
    • Reference Number: FC.PP.011
    • PDF Publish Date: 3/1/2024

    Payment Policy: EEG in the Evaluation of Headache
    • Reference Number: FC.PP.014
    • PDF Publish Date: 10/1/2023

    Payment Policy: Emergency Department Evaluation and Management Claim Adjustment
    • Reference Number: FC.PP.005
    • PDF Publish Date: 5/1/2024

    Payment Policy: Endometrial Ablation
    • Reference Number: FC.PP.010
    • PDF Publish Date: 4/1/2023 

    Payment Policy: Evaluation and Management Claim Adjustment
    • Reference Number: FC.PP.006
    • PDF Publish Date: 6/1/2023

    Payment Policy: Evoked Potential Testing
    • Reference Number: FC.PP.019
    • PDF Publish Date: 12/1/2023

    Payment Policy: Gastrointestinal Pathogen Nucleic Acid Detection Panel
    • Reference Number: FC.PP.034
    • PDF Publish Date: 11/1/2022

    Payment Policy: Helicobacter Pylori Serology Testing
    • Reference Number: FC.PP.018
    • PDF Publish Date: 10/1/2023

    Payment Policy: Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy
    • Reference Number: FC.PP.028
    • PDF Publish Date: 4/1/2023

    Payment Policy: Maximum Units of Service
    • Reference Number: CC.PP.007
    • PDF Publish Date: 1/1/2023

    Payment Policy: Measure of Serum 1.25 (Vitamin D)
    • Reference Number: FC.PP.012
    • PDF Publish Date: 12/1/2023

    Payment Policy: National Diabetes Prevention Program (NDPP)
    • Reference Number: FC.PP.021
    • PDF Publish Date: 6/1/2023

    Payment Policy: Non-obstetrical and Obstetrical Transabdominal & Transvaginal Ultrasounds
    • Reference Number: FC.PP.009
    • PDF Publish Date: 3/1/2023

    Payment Policy: Pre-Payment and Post-Payment Review (Non-Medicare)
    • Reference Number: FC.PP.007
    • PDF Publish Date: 11/1/2021

    Payment Policy: Pre-Payment and Post-Payment Review (Medicare)
    • Reference Number: FC.PP.008
    • PDF Publish Date: 1/1/2022

    Payment Policy: Pulmonary Function Testing
    • Reference Number: FC.PP.035
    • PDF Publish Date: 11/1/2022

    Payment Policy: Renal Hemodialysis
    • Reference Number: CC.PP.067
    • PDF Publish Date: 9/1/2022

    Payment Policy: Robotic Surgery
    • Reference Number: CC.PP.050
    • PDF Publish Date: 3/1/2023

    Payment Policy: Sepsis Diagnosis
    • Reference Number: CC.PP.073
    • PDF Publish Date: 3/1/2023

    Payment Policy: Spinal Muscular Atrophy (SMA) Carrier Screening in Pregnancy
    • Reference Number: FC.PP.033
    • PDF Publish Date: 6/1/2022

    Payment Policy: Status "B" Bundled Services
    • Reference Number: CC.PP.046
    • PDF Publish Date: 1/1/2023

    Payment Policy: Status "P" Bundled Services
    • Reference Number: CC.PP.049
    • PDF Publish Date: 1/1/2023

    Payment Policy: Testing for Select Genitourinary Conditions
    • Reference Number: FC.PP.022
    • PDF Publish Date: 12/1/2023

    Payment Policy: Thyroid Insulin Tests in Pediatrics
    • Reference Number: FC.PP.013
    • PDF Publish Date: 10/1/2023

    Payment Policy: Transgender Services Billing Requirements
    • Reference Number: CC.PP.047
    • PDF Publish Date: 4/1/2023

    Payment Policy: Ultrasound in Pregnancy
    • Reference Number: FC.PP.029
    • PDF Publish Date: 12/1/2023

    Payment Policy: Urodynamic Testing
    • Reference Number: FC.PP.023
    • PDF Publish Date: 1/1/2024