Effective Date: 01.01.2021 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Effective Date: 01.01.2021 – This policy addresses genitourinary pathogen nucleic acid detection panel testing to evaluate symptomatic women for vaginitis. Effective Date: 01.01.2021 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Effective Date: 10.14.2020 – This policy addresses hepatitis screening. Applicable Procedure Codes: J0178, J0179, J2503, J2778, J9035, Q5107, Q5118. Applicable Procedure Code: 19499. This policy addresses photosensitive drugs used in photodynamic therapy. This policy addresses magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Applicable Procedure Code: G0472. Applicable Procedure Code: 19318. They are also used to decide whether a given health service is medically necessary. This policy addresses computerized corneal topography. Applicable Procedure Codes: 00811, 00812, 74263, 81528, 82270, G0104, G0105, G0106, G0120, G0121, G0122, G0328. This policy addresses coronary fractional flow reserve using computed tomography (FFR-CT) for the evaluation of coronary artery disease (CAD), including the HeartFlow® FFRct technology. This policy addresses multiple-seizure electroconvulsive therapy (MECT). Our selection of individual and family health insurance plans offers you the perfect coverage. Applicable Procedure Code: L3250. This policy addresses non-implantable pelvic floor electrical stimulators for the treatment of stress and/or urge urinary incontinence. Updated Clinical Practice Guidelines for Hawaii, Community Plan Reimbursement Policies of Hawaii, Idaho UnitedHealthcare Medicare Advantage Plans, Illinois UnitedHealthcare Medicare Advantage Plans, Community Plan Reimbursement Policies of Indiana, Community Plan of Indiana Medical & Drug Policies and Coverage Determination Guidelines, Community Plan Reimbursement Policies of Iowa, Kansas Erickson Advantage® Freedom/Signature Plans, Kansas UnitedHealthcare® MedicareDirect (PFFS), Benefit enhancements for Kansas dual special needs plan (DSNP), Community Plan Reimbursement Policies of Kansas, Kentucky UnitedHealthcare® MedicareDirect (PFFS), Community Plan Reimbursement Policies of Kentucky, Community Plan of Kentucky Medical & Drug Policies and Coverage Determination Guidelines, Benefit enhancements for Louisiana dual special needs plan (DSNP), Community Plan Reimbursement Policies of Louisiana, Maryland Erickson Advantage® Freedom/Signature Plans. Applicable Procedure Codes: 0068U, 87480, 81513, 81514, 87481, 87482, 87510, 87511, 87512, 87660, 87661, 87797, 87798, 87799, 87800, 87801. Effective Date: 12.01.2020 – This policy addresses sensory integration therapy and auditory integration training. GRP 79171 GPS-1 (G-36000-4). Applicable Procedure Codes: 67221, 67225. Effective Date: 04.01.2020 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055. Effective Date: 02.01.2021 – This policy addresses the use of Vyepti™ (Eptinezumab) for the treatment of chronic and episodic migraine. A monthly notice of recently approved and/or revised Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDGs), and Utilization Review Guidelines (URGs) is provided below for your review. Applicable Procedure Codes: G0248, G0249, G0250. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112. Applicable Procedure Codes: J0596, J0597, J0598, J1290. Effective Date: 04.01.2020 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Effective Date: 02.01.2021 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Udenyca, Zarxio, and Ziextenzo. This policy addresses diagnostic pap smears and related services. This policy addresses intravenous histamine therapy. This policy addresses Category III CPT codes used to track the utilization of emerging technologies, services, and procedures. Applicable Procedure Codes: 94681, 99199, G9147. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66183. Applicable Procedure Codes: J3490, S0013. Have health insurance through your employer or have an individual plan? This policy addresses electronic retinal prosthesis. Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335. Applicable Procedure Codes: E0172, E0627, E0629. Applicable Procedure Code: J0567. This policy addresses carbon dioxide (5 percent) and oxygen (95 percent) inhalation therapy for the treatment of inner ear disease. Applicable Procedures Code: J7352. You must be an AARP member to enroll in an AARP Medicare Supplement Plan. Effective Date: 02.01.2021 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: C9399, J0129, J0180, J0221, J0222, J0223, J0256, J0257, J0490, J0584, J0638, J0717, J0791, J0896, J1300, J1301, J1303, J1322, J1428, J1429, J1458, J1602, J1743, J1745, J1746, J1786, J1931, J2840, J3032, J3060, J3241, J3245, J3262, J3357, J3358, J3380, J3385, J3397, J3490, Q5103, Q5104, Q5121. Applicable Procedure Codes: 82306, 82652. Applicable Procedure Code: J0897. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment. The new plan will offer access to a large, comprehensive, high-quality network of care providers in the Bay Area who are affiliated with Canopy Health. Applicable Procedure Codes: L8499, L8699. This policy addresses negative pressure wound therapy pumps and supplies. UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. This policy addresses hydrophilic contact lens for corneal bandage. Applicable Procedure Codes: 86890, 86891, 86985, P9010, P9011, P9012, P9016, P9017, P9021, P9022, P9023, P9038, P9039, P9040, P9043, P9044, P9048, P9051, P9054, P9056, P9057, P9058, P9059, P9060, P9070, P9071, P9099. This policy addresses hospital beds for patient home use. Applicable Procedure Codes: 33140, 33141. Applicable Procedure Code: 97610. Applicable Procedure Code: J9206. Applicable Procedure Codes: 66982, 66984. Applicable Procedure Code: M0076. This policy addresses deep brain stimulation for essential tremor and Parkinsonâs disease. Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. This policy addresses antigens administered sublingually. Applicable Procedure Codes: 81479, 81599, 84999, 85999, 86849. Applicable Procedure Codes: 76497, 76498. Applicable Procedure Codes: A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A9270, A9275, E0607, E0620, E2100, E2101. Applicable Procedure Codes: E0193, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271, E0272, E0273, E0274, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0910, E0911, E0912, E0940. Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106. A4467, A9270, K0672, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1851, L1852, L1860, L2275, L2320, L2330, L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2780, L2785, L2795, L2800, L2810, L2820, L2830, L2999, L4002, L4205, L4210, L9900. This policy addresses transfer factor for treatment of multiple sclerosis. Effective Date: 02.01.2021 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: 95165, 95199. Effective Date: 02.01.2021 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Go Paperless: Good for the planet. Applicable Procedure Codes: 21740, 21742, 21743. Effective Date: 01.01.2021 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. This policy addresses BRCA1 and BRCA2 genetic testing for hereditary cancers. This policy addresses the rental or purchase of seat lifts. Applicable Procedure Code: 90378. Applicable Procedure Codes: 65760, 65765, 65767, 65771. Applicable Procedure Codes: J1950, J3315, J3316, J9155, J9202, J9217, J9225, J9226. Applicable Procedure Codes: 86704, 86706, 87340, 87341, G0499. 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Applicable Procedure Code: 37799. Effective Date: 11.01.2020 – This policy addresses the use of buprenorphine (Probuphine® and Sublocade™) for the treatment of opioid dependence/opioid use disorder. Your UnitedHealthcare Medicare plans provider network might include primary care providers, medical and surgical specialists, pharmacists, hospitals, outpatient facilities, labs, and/or imaging centers. Applicable Procedure Codes: 77063, 77065, 77066, 77067, G0279. 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 15788, 15789, 15792, 15793, 17000, 17003, 17004, 17110, 17111, 96567, 96573, 96574, J7308, J7309. 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Applicable Procedure Codes: L8679, L8680, L8681, L8683, L8685, L8686, L8687, L8688, L8689, L8695. At UnitedHealthcare, we are committed to improving the health care system. Applicable Procedure Codes: 97799, 99183, 99199, A4575, E0446, G0277. Applicable Procedure Codes: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688. This policy addresses extracranial-intracranial (EC-IC) arterial bypass surgery for the treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries. Applicable Procedure Codes: 48160, 48554. Applicable Procedure Code: 0398T. Applicable Procedure Code: 0184T. Effective Date: 05.01.2020 – This policy addresses clinical trials. This policy addresses biofeedback therapy for the treatment of urinary incontinence. Effective Date: 11.01.2020 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Codes: 90283, 90284, J1459, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599. Effective Date: 01.01.2021 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. This policy addresses genetic testing guidelines for Lynch syndrome. Applicable Procedure Codes: 33202, 33203, 33215, 33216, 33217, 33218, 33220, 33223, 33224, 33225, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 93260, 93261, 93282, 93283, 93284, 93289, 93295, 93644, G0448. Effective Date: 07.01.2020 – This policy addresses laser interstitial thermal therapy. 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03/01/2021 – UnitedHealthcare Commercial Medical Policy Update Bulletin: March 2021, UnitedHealthcare Commercial Medical Policy Update Bulletin Archive, Medical Records Requirements for Pre-Service, Attended Polysomnography for Evaluation of Sleep Disorders – Commercial Medical Policy, 17-Alpha-Hydroxyprogesterone Caproate (Makena® and 17P) – Commercial Medical Benefit Drug Policy, Ablative Treatment for Spinal Pain – Commercial Medical Policy, Abnormal Uterine Bleeding and Uterine Fibroids – Commercial Medical Policy, Actemra® (Tocilizumab) Injection for Intravenous Infusion – Commercial Medical Benefit Drug Policy, Adakveo® (Crizanlizumab-Tmca) – Commercial Medical Benefit Drug Policy, Airway Clearance Devices – Commercial Medical Policy, Alpha1-Proteinase Inhibitors – Commercial Medical Benefit Drug Policy, Ambulance Services – Commercial Coverage Determination Guideline, Articular Cartilage Defect Repairs – Commercial Medical Policy, Athletic Pubalgia Surgery – Commercial Medical Policy, Autologous Cellular Therapy for Certain Indications – Commercial Medical Policy, Balloon Sinus Ostial Dilation – Commercial Medical Policy, Bariatric Surgery Bariatric Surgery – Commercial Medical Policy, Benlysta® (Belimumab) – Commercial Medical Benefit Drug Policy, Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair – Commercial Coverage Determination Guideline, Bone or Soft Tissue Healing and Fusion Enhancement Products – Commercial Medical Policy, Botulinum Toxins A and B – Commercial Medical Benefit Drug Policy, Breast Imaging for Screening and Diagnosing Cancer – Commercial Medical Policy, Breast Reconstruction Post Mastectomy and Poland Syndrome – Commercial Coverage Determination Guideline, Breast Reduction Surgery – Commercial Coverage Determination Guideline, Breast Repair/Reconstruction Not Following Mastectomy – Commercial Coverage Determination Guideline, Brineura® (Cerliponase Alfa) – Commercial Medical Benefit Drug Policy, Bronchial Thermoplasty – Commercial Medical Policy, Buprenorphine (Probuphine® & Sublocade®) – Commercial Medical Benefit Drug Policy, Cardiac Event Monitoring – Commercial Medical Policy, Cardiovascular Disease Risk Tests – Commercial Medical Policy, Carrier Testing for Genetic Diseases – Commercial Medical Policy, Catheter Ablation for Atrial Fibrillation – Commercial Medical Policy, Cell-Free Fetal DNA Testing – Commercial Medical Policy, Chelation Therapy for Non-Overload Conditions – Commercial Medical Policy, Chemosensitivity and Chemoresistance Assays in Cancer – Commercial Medical Policy, Chemotherapy Observation or Inpatient Hospitalization – Commercial Utilization Review Guideline, Chromosome Microarray Testing (Non-Oncology Conditions) – Commercial Medical Policy, Cimzia® (Certolizumab Pegol) – Commercial Medical Benefit Drug Policy, Clinical Trials – Commercial Coverage Determination Guideline, Clotting Factors, Coagulant Blood Products & Other Hemostatics – Commercial Medical Benefit Drug Policy, Cochlear Implants – Commercial Medical Policy, Cognitive Rehabilitation – Commercial Medical Policy, Collagen Crosslinks and Biochemical Markers of Bone Turnover – Commercial Medical Policy, Complement Inhibitors (Soliris® & Ultomiris®) – Commercial Medical Benefit Drug Policy, Computed Tomographic Colonography – Commercial Medical Policy, Computer-Assisted Surgical Navigation for Musculoskeletal Procedures – Commercial Medical Policy, Computerized Dynamic Posturography – Commercial Medical Policy, Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Commercial Medical Policy, Core Decompression for Avascular Necrosis – Commercial Medical Policy, Corneal Hysteresis and Intraocular Pressure Measurement – Commercial Medical Policy, Cosmetic and Reconstructive Procedures – Commercial Coverage Determination Guideline, Crysvita® (Burosumab-Twza) – Commercial Medical Benefit Drug Policy, Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis – Commercial Medical Policy, Deep Brain and Cortical Stimulation – Commercial Medical Policy, Denosumab (Prolia® & Xgeva®) – Commercial Medical Benefit Drug Policy, Discogenic Pain Treatment – Commercial Medical Policy, Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements – Commercial Coverage Determination Guideline, Elbow Replacement Surgery (Arthroplasty) – Commercial Medical Policy, Electric Tumor Treatment Field Therapy – Commercial Medical Policy, Electrical and Ultrasound Bone Growth Stimulators – Commercial Medical Policy, Electrical Bioimpedance for Cardiac Output Measurement – Commercial Medical Policy, Electrical Stimulation and Electromagnetic Therapy for Wounds – Commercial Medical Policy, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Commercial Medical Policy, Electroencephalographic (EEG) Monitoring and Video Recording – Commercial Medical Policy, Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – Commercial Medical Policy, Emergency Health Care Services and Urgent Care Center Services – Commercial Coverage Determination Guideline, Enteral Nutrition – Commercial Coverage Determination Guideline, Entyvio® (Vedolizumab) – Commercial Medical Benefit Drug Policy, Enzyme Replacement Therapy – Commercial Medical Benefit Drug Policy, Epidural Steroid and Facet Injections for Spinal Pain – Commercial Medical Policy, Epiduroscopy, Epidural Lysis of Adhesions and Discography – Commercial Medical Policy, Erythropoiesis-Stimulating Agents – Commercial Medical Benefit Drug Policy, Evenity® (Romosozumab-Aqqg) – Commercial Medical Benefit Drug Policy, Exondys 51® (Eteplirsen) – Commercial Medical Benefit Drug Policy, Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds – Commercial Medical Policy, Fecal Calprotectin Testing – Commercial Medical Policy, Femoroacetabular Impingement Syndrome – Commercial Medical Policy, Functional Endoscopic Sinus Surgery (FESS) – Commercial Medical Policy, Gamifant® (Emapalumab-Lzsg) – Commercial Medical Benefit Drug Policy, Gastrointestinal Motility Disorders, Diagnosis and Treatment – Commercial Medical Policy, Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Commercial Medical Policy, Gender Dysphoria Treatment – Commercial Medical Policy, Genetic Testing for Cardiac Disease – Commercial Medical Policy, Genetic Testing for Hereditary Cancer – Commercial Medical Policy, Genetic Testing for Neuromuscular Disorders – Commercial Medical Policy, Genitourinary Pathogen Nucleic Acid Detection Panel Testing – Commercial Medical Policy, Givlaari® (Givosiran) – Commercial Medical Benefit Drug Policy, Glaucoma Surgical Treatments – Commercial Medical Policy, Gonadotropin Releasing Hormone Analogs – Commercial Medical Benefit Drug Policy, Gynecomastia Treatment – Commercial Coverage Determination Guideline, Habilitative Services and Outpatient Rehabilitation Therapy – Commercial Coverage Determination Guideline, Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable – Commercial Medical Policy, Hepatitis Screening – Commercial Medical Policy, Hereditary Angioedema (HAE), Treatment and Prophylaxis – Commercial Medical Benefit Drug Policy, Hip Resurfacing and Replacement Surgery (Arthroplasty) – Commercial Medical Policy, Home Health Care – Commercial Coverage Determination Guideline, Home Hemodialysis – Commercial Medical Policy, Home Traction Therapy – Commercial Medical Policy, Hysterectomy for Benign Conditions – Commercial Medical Policy, Ilaris® (Canakinumab) – Commercial Medical Benefit Drug Policy, Ilumya™ (Tildrakizumab-Asmn) – Commercial Medical Benefit Drug Policy, Immune Globulin (IVIG and SCIG) – Commercial Medical Benefit Drug Policy, Immune Globulin – Site of Care – Commercial Utilization Review Guideline, Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors – Commercial Medical Policy, Implanted Electrical Stimulator for Spinal Cord – Commercial Medical Policy, Infertility Diagnosis and Treatment – Commercial Medical Policy, Infertility Services – Commercial Coverage Determination Guideline, Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Commercial Medical Benefit Drug Policy, Inhaled Nitric Oxide for Infants – Commercial Medical Policy, Inpatient Pediatric Feeding Programs – Commercial Utilization Review Guideline, Intensity-Modulated Radiation Therapy – Commercial Medical Policy, Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) – Commercial Medical Policy, Intrauterine Fetal Surgery – Commercial Medical Policy, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease – Commercial Medical Benefit Drug Policy, Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) – Commercial Medical Benefit Drug Policy, Ketalar® (Ketamine) and Spravato® (Esketamine) – Commercial Medical Benefit Drug Policy, Knee Replacement Surgery (Arthroplasty), Total and Partial – Commercial Medical Policy, Krystexxa® (Pegloticase) – Commercial Medical Benefit Drug Policy, Laser Interstitial Thermal Therapy – Commercial Medical Policy, Lemtrada (Alemtuzumab) – Commercial Medical Benefit Drug Policy, Light and Laser Therapy – Commercial Medical Policy, Lithotripsy for Salivary Stones – Commercial Medical Policy, Lower Extremity Invasive Diagnostic and Endovascular Procedures – Commercial Medical Policy, Luxturna™ (Voretigene Neparvovec-Rzyl) – Commercial Medical Benefit Drug Policy, Macular Degeneration Treatment Procedures – Commercial Medical Policy, Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service – Commercial Utilization Review Guideline, Manipulation Under Anesthesia – Commercial Medical Policy, Manipulative Therapy – Commercial Medical Policy, Maximum Dosage and Frequency – Commercial Medical Benefit Drug Policy, Mechanical Stretching Devices – Commercial Medical Policy, Meniscus Implant and Allograft – Commercial Medical Policy, Mifeprex® (Mifepristone) – Commercial Medical Benefit Drug Policy, Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia – Commercial Medical Policy, Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – Commercial Medical Policy, Motorized Spinal Traction – Commercial Medical Policy, Negative Pressure Wound Therapy – Commercial Medical Policy, Nerve Graft to Restore Erectile Function During Radical Prostatectomy – Commercial Medical Policy, Neurophysiologic Testing and Monitoring – Commercial Medical Policy, Neuropsychological Testing Under the Medical Benefit – Commercial Medical Policy, Obstructive Sleep Apnea Treatment – Commercial Medical Policy, Occipital Neuralgia and Headache Treatment – Commercial Medical Policy, Ocrevus® (Ocrelizumab) – Commercial Medical Benefit Drug Policy, Off-Label/Unproven Specialty Drug Treatment – Commercial Medical Benefit Drug Policy, Office Based Procedures – Site of Service – Commercial Utilization Review Guideline, Omnibus Codes – Commercial Medical Policy, Oncology Medication Clinical Coverage – Commercial Medical Benefit Drug Policy, Onpattro® (Patisiran) – Commercial Medical Benefit Drug Policy, Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors – Commercial Medical Benefit Drug Policy, Orencia® (Abatacept) Injection for Intravenous Infusion – Commercial Medical Benefit Drug Policy, Orthognathic (Jaw) Surgery – Commercial Coverage Determination Guideline, Outpatient Surgical Procedures – Site of Service – Commercial Utilization Review Guideline, Oxlumo™ (Lumasiran) – Commercial Medical Benefit Drug Policy, Panniculectomy and Body Contouring Procedures – Commercial Coverage Determination Guideline, Parsabiv® (Etelcalcetide) – Commercial Medical Benefit Drug Policy, Pectus Deformity Repair – Commercial Coverage Determination Guideline, Percutaneous Patent Foramen Ovale (PFO) Closure – Commercial Medical Policy, Percutaneous Vertebroplasty and Kyphoplasty – Commercial Medical Policy, Pharmacogenetic Testing – Commercial Medical Policy, Plagiocephaly and Craniosynostosis Treatment – Commercial Medical Policy, Pneumatic Compression Devices – Commercial Medical Policy, Preimplantation Genetic Testing – Commercial Medical Policy, Preventive Care Services – Commercial Coverage Determination Guideline, Private Duty Nursing (PDN) Services – Commercial Coverage Determination Guideline, Prolotherapy and Platelet Rich Plasma Therapies – Commercial Medical Policy, Propranolol Treatment for Infantile Hemangiomas: Inpatient Protocol – Commercial Utilization Review Guideline, Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs – Commercial Coverage Determination Guideline, Proton Beam Radiation Therapy – Commercial Medical Policy, Provider Administered Drugs – Site of Care – Commercial Utilization Review Guideline, Radicava® (Edaravone) – Commercial Medical Benefit Drug Policy, Reblozyl® (Luspatercept-Aamt) – Commercial Medical Benefit Drug Policy, Repository Corticotropin Injection (Acthar® Gel) – Commercial Medical Benefit Drug Policy, Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) – Commercial Medical Benefit Drug Policy, Review at Launch for New to Market Medications – Commercial Medical Benefit Drug Policy, Rhinoplasty and Other Nasal Surgeries – Commercial Coverage Determination Guideline, Rituximab (Rituxan®, Ruxience®, & Truxima®) – Commercial Medical Benefit Drug Policy, Scenesse® (Afamelanotide) – Commercial Medical Benefit Drug Policy, Screening Colonoscopy Procedures – Site of Service – Commercial Utilization Review Guideline, Self-Administered Medications – Commercial Medical Benefit Drug Policy, Sensory Integration Therapy and Auditory Integration Training – Commercial Medical Policy, Shoulder Replacement Surgery (Arthroplasty) – Commercial Medical Policy, Simponi Aria® (Golimumab) Injection for Intravenous Infusion – Commercial Medical Benefit Drug Policy, Skilled Care and Custodial Care Services – Commercial Coverage Determination Guideline, Skin and Soft Tissue Substitutes – Commercial Medical Policy, Sodium Hyaluronate – Commercial Medical Benefit Drug Policy, Somatostatin Analogs – Commercial Medical Benefit Drug Policy, Spinal Ultrasonography – Commercial Medical Policy, Spinraza® (Nusinersen) – Commercial Medical Benefit Drug Policy, Stelara® (Ustekinumab) – Commercial Medical Benefit Drug Policy, Subcutaneous Implantable Naltrexone Pellets – Commercial Medical Benefit Drug Policy, Sublingual Immunotherapy – Commercial Medical Policy, Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins – Commercial Medical Policy, Surgical Treatment for Spine Pain – Commercial Medical Policy, Synagis® (Palivizumab) – Commercial Medical Benefit Drug Policy, Temporomandibular Joint Disorders – Commercial Medical Policy, Tepezza® (Teprotumumab-Trbw) – Commercial Medical Benefit Drug Policy, Testosterone Replacement or Supplementation Therapy – Commercial Medical Benefit Drug Policy, Total Artificial Disc Replacement for the Spine – Commercial Medical Policy, Total Artificial Heart – Commercial Medical Policy, Transcatheter Heart Valve Procedures – Commercial Medical Policy, Transcranial Magnetic Stimulation – Commercial Medical Policy, Transpupillary Thermotherapy – Commercial Medical Policy, Trogarzo® (Ibalizumab-Uiyk) – Commercial Medical Benefit Drug Policy, Tysabri® (Natalizumab) – Commercial Medical Benefit Drug Policy, Umbilical Cord Blood Harvesting and Storage – Commercial Medical Policy, Unicondylar Spacer Devices for Treatment of Pain or Disability – Commercial Medical Policy, Uplizna® (Inebilizumab-Cdon) – Commercial Medical Benefit Drug Policy, Vaccines – Commercial Medical Benefit Drug Policy, Vagus and External Trigeminal Nerve Stimulation – Commercial Medical Policy, Vertebral Body Tethering for Scoliosis – Commercial Medical Benefit Drug Policy, Viltepso® (Viltolarsen) – Commercial Medical Benefit Drug Policy, Virtual Upper Gastrointestinal Endoscopy – Commercial Medical Policy, Visual Information Processing Evaluation and Orthoptic and Vision Therapy – Commercial Medical Policy, Vyepti™ (Eptinezumab-Jjmr) – Commercial Medical Benefit Drug Policy, Vyondys 53™ (Golodirsen) – Commercial Medical Benefit Drug Policy, Warming Therapy and Ultrasound Therapy for Wounds – Commercial Medical Policy, White Blood Cell Colony Stimulating Factors – Commercial Medical Benefit Drug Policy, Whole Exome and Whole Genome Sequencing – Commercial Medical Policy, Xolair® (Omalizumab) – Commercial Medical Benefit Drug Policy, Zolgensma® (Onasemnogene Abeparvovec-Xioi) – Commercial Medical Benefit Drug Policy, Zulresso™ (Brexanolone) – Commercial Medical Benefit Drug Policy.
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