Archived Policies

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A

• Actinic Keratosis 
• Actinic Keratosis - Archived Effective Date 4/24/2026

C

• Clinical Drug Testing in Addiction Treatment Programs and Pain Management Programs
• Comfort and Convenience Items
• Comfort and Convenience Items - Archived Effective Date 3/31/2026

• Comfort and Convenience Items - Archived effective 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 5/31/2026

G

• Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (BRAC)
• Gender Affirmation
• Genicular Nerve Blocks - Archived effective 5/31/2026

H

• Home Ventilators

I

• Intraoperative Neurophysiological Testing 
• Inhaled Nitric Oxide (iNO) 

N

• 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
• 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

S

• Screening for Vitamin D Deficiency
• Screening for Vitamin D Deficiency
• Short-Term Continuous Glucose Monitors 
• Skilled Private Duty Nursing (PDN) 
• Spinal Orthoses for Scoliosis
• Spinal Orthoses for Scoliosis

V

• Vaginitis Diagnostic Testing 
• Vitamin B-12 Testing 
• Vitamin B-12 Testing