Archived Policies
A
- Actinic Keratosis
- Actinic Keratosis - Archived Effective Date 4/24/2026
C
-
Clinical Criteria for UM Decisions & Medical Necessity Review - Archived Effective Date 2/1/2026
- Clinical Drug Testing in Addiction Treatment Programs and Pain Management Programs
- Clinical Drug Testing in Addiction Treatment Programs and Pain Management Programs - Archived Effective Date 7.23.2025
- Comfort and Convenience Items
- Comfort and Convenience Items - Archived Effective Date 3/31/2026
-
Comfort and Convenience Items - Archived Effective Date 5/31/2026
- Cosmetic Procedures
- Cosmetic Procedures
- Coverage of Clinical Trials
- COVID-19 Treatment
- COVID-19 Treatment
E
- Experimental-Investigational Services
- Experimental-Investigational Services - Archived Effective Date 2/6/2026
- Experimental-Investigational Services - Archived Effective Date 5/31/2026
G
- Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (BRAC)
- Genetic Testing for Hereditary Cancers: Breast, Ovarian, and Pancreatic
- Gender Affirmation
- Gender Affirmation - Archived Effective Date 6/2026
- Genicular Nerve Blocks - Archived Effective Date 5/31/2026
H
I
- Intraoperative Neurophysiological Testing
- Intraoperative Neurophysiological Testing - Archived Effective Date 4/16/2026
- Inhaled Nitric Oxide (iNO)
L
M
- Medical Necessity Determination Policy for Medicare Covered Services Without Established Criteria - Archived Effective Date 10/22/2025
N
- Non-invasive Prenatal Testing (NIPT) - Cell-Free DNA
- Non-invasive Prenatal Testing (NIPT) - Cell-Free DNA
- Navigational Bronchoscopy - Archived Effective Date 4/24/2026
P
- Pancreatic Islet Cell Transplantation - Archived Effective Date 1/23/26
- Platelet Rich Plasma
- Proprietary Laboratory Testing - Archived Effective Date 12/31/2025
- Proprietary Laboratory Testing - Archived Effective Date 2/28/26
- Proprietary Laboratory Testing - Archived Effective Date 2/28/26
- Proprietary Laboratory Testing - Archived Effective Date 3/31/26
- Proprietary Laboratory Testing - Archived Effective Date 6/30/2026
S
- Screening for Vitamin D Deficiency
- Screening for Vitamin D Deficiency
- Sepsis - Archived Effective Date 6/7/2026
- Short-Term Continuous Glucose Monitors
- Skilled Private Duty Nursing (PDN)
- Skilled Private Duty Nursing (PDN) - Archived Effective Date 3/30/2026
- Skin Lesion Surveillance Technologies
- Speech Therapy - Archived Effective Date 4/23/2026
- Spinal Orthoses for Scoliosis
- Spinal Orthoses for Scoliosis
T
- Thyroid Screening
- Transcranial Magnetic Stimulation (TMS) - Archived Effective Date 6/2026
- Transplant Services - Archived Effective Date 4/23/26