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.
- ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- LAB.00011 Selected Protein Biomarker Algorithmic Assays
- LAB.00028 Serum Biomarker Tests for Multiple Sclerosis
- MED.00140 Gene Therapy for Beta Thalassemia
- OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis
- OR-PR.00007 Microprocessor Controlled Knee-Ankle-Foot Orthosis
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- TRANS.00039 Portable Normothermic Organ Perfusion Systems
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-MED-39 Bone Mineral Density Testing Measurement
- CG-MED-83 Site of Care: Specialty Pharmaceuticals
- CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
- CG-SURG-01 Colonoscopy
- CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-79 Implantable Infusion Pumps
- CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
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