Historical Medical Policies and Clinical UM Guidelines
Historical Medical Policies
Medical policies contained within this page are historical and not the most current versions. Current medical policy content may be accessed from the Medical Policies and Clinical UM Guidelines page. Implementation dates of the most current versions vary per state notification requirements.
Historical Clinical UM Guidelines
Clinical UM guidelines contained within this page are historical and not the most current versions. Current clinical UM guideline content may be accessed from the Medical Policies and Clinical UM Guidelines page. Implementation dates of the most current versions vary per state notification requirements.
- CG-ANC-06 Ambulance Services: Ground; Non-Emergent
- CG-DME-31 Powered Wheeled Mobility Devices
- CG-DME-36 Pediatric Gait Trainers
- CG-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
- CG-GENE-16 BRCA Genetic Testing
- CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
- CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing
- CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
- CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
- CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
- CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus
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