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.
- LAB.00026 Systems Pathology Testing for Prostate Cancer
- LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00097 Scoliosis Surgery
- SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
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-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
- CG-DME-44 Electric Tumor Treatment Field (TTF)
- CG-GENE-13 Genetic Testing for Inherited Diseases
- CG-GENE-18 Genetic Testing for TP53 Mutations
- CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing
- CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing
- CG-MED-92 Foot Care Services
- CG-SURG-09 Temporomandibular Disorders
- CG-SURG-70 Gastric Electrical Stimulation
- CG-SURG-94 Keratoprosthesis
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
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