| Guideline for Benefit Interpretation | Reviewed
|
|---|
Abortion
| 1/1/26
|
Acupuncture
| 4/1/25
|
Allergy Testing/Desensitization
| 4/1/25
|
Ambulance Services
| 4/1/25
|
Ambulatory Blood Pressure Monitoring
| 4/1/25
|
Amniocentesis
| 4/1/25
|
Apnea Monitors
| 4/1/25
|
Assistant Surgeon
| 4/1/25
|
Autism Spectrum Disorder (ASD)
| 6/1/26
|
Automatic External Defibrillator
| 4/1/25
|
Automatic Implantable Cardioverter Defibrillator (AICD)
| 4/1/25
|
Autopsy Examination
| 4/1/25
|
BRCA (Breast Cancer Susceptibility) Testing and Related Genetic Counseling
| 4/1/25
|
Biofeedback Therapy
| 4/1/25
|
Blood and Blood Derivatives
| 4/1/25
|
Boarder Babies
| 4/1/25 |
Bone Marrow Transplantation
| 4/1/25 |
Botulinum Toxin
| 4/1/25
|
Breast Screening
| 1/1/26 |
Breast Surgery
| 4/1/25
|
Cardiac Rehabilitation
| 4/1/25
|
CAR-T Therapy
| 1/1/25
|
Chemical Dependency/Substance Use Disorder (SUD) Services
| 1/1/26 |
Chemotherapy
| 4/1/25 |
Chiropractic Services
| 4/1/25 |
Cochlear Implantation
| 4/1/25
|
Cognitive Therapy
| 4/1/25
|
Collagen Implant
| 4/1/25 |
Computerized Knee Evaluation
| 4/1/25
|
Contact Lenses/Eyeglasses
| 4/1/25 |
Cosmetic/Reconstructive Surgery
| 4/1/25
|
Custodial Care
| 4/1/25
|
Day Rehabilitation Program
| 4/1/25
|
Dental
| 4/1/25 |
Diabetes Self-Management
| 4/1/25
|
Drugs
| 5/1/26
|
Durable Medical Equipment (DME)
| 4/1/25
|
Earplugs
| 4/1/25 |
Electrical Bone Growth Stimulation
| 4/1/25 |
Emergency Communication Devices
| 4/1/25 |
Emergency Services
| 4/1/25
|
Epidural Anesthesia
| 4/1/25
|
Erythropoietin (EPO)
| 4/1/25
|
| Family Planning | 4/1/25
|
| Fertility Preservation | 4/1/25 |
Growth Factors for Wound Healing
| 4/1/25 |
Growth Hormone Therapy
| 4/1/25
|
Health Examinations
| 4/1/25 |
Hearing Aids
| 5/1/26 |
Hearing Screening
| 4/1/25 |
Hematopoietic Growth Factors (HGF)
| 4/1/25
|
Hemodialysis and Peritoneal Dialysis
| 4/1/25
|
Hepatitis B Vaccine
| 4/1/25
|
Home Health Care Services
| 4/1/25
|
Home Uterine Activity Monitoring (HUAM)
| 4/1/25
|
Hospice Care
| 4/1/25 |
Hospital Beds
| 4/1/25
|
Hyperalimentation (TPN)
| 4/1/25
|
Hyaluronan (Durolane, Orthovisc, Monovisc, Euflexxa, Supartz, Hymovis, Gel-ONE, GelSyn-3, GenVisc 850, Hyalgan, Visco-3, Synvisc/Synvisc-One and TriVisc)+
| 5/1/26
|
Hyperthermia Therapy
| 4/1/25
|
Hypnotherapy (Hypnosis)
| 4/1/25 |
Immunizations
| 1/1/25 |
Infertility and Fertility Treatment
| 5/1/26
|
Infusion Pumps (Implanted-Permanent)
| 4/1/25 |
Infusion Pumps (Portable - Temporary)
| 4/1/25
|
Intravenous Immunoglobulin (IVIG)
| 4/1/25 |
Investigational Procedures, Drugs, Devices, Services, and/or Supplies
| 4/1/25
|
Laboratory Tests
| 4/1/25 |
Lithotripsy (Percutaneous and Extracorporeal)
| 4/1/25 |
Lupron/Lupron Depot
| 4/1/25 |
Mammography
| 1/1/26 |
Maternity/Obstetrical Care
| 1/1/26
|
Medical Supplies (Non-Durable Medical Equipment)
| 4/1/25 |
Mental Health Care (Inpatient)
| 3/1/26
|
Mental Health Care (Outpatient)
| 3/1/26 |
| Mobile Integrated Health Services (MIH) | 1/1/26 |
Monoclonal Antibody Imaging
| 4/1/25 |
Naprapathic Services
| 4/1/25
|
Nerve Stimulators (Percutaneous, Transcutaneous, Implanted)
| 4/1/25
|
Neuromuscular Stimulation for Scoliosis
| 4/1/25
|
Nutritional Services (Dietary Counseling)
| 4/1/25
|
Nutritional Supplements/Enteral Nutrition
| 4/1/25 |
Obesity
| 4/1/25 |
Obstructive Sleep Apnea (OSA) Syndrome
| 12/1/24 |
Occupational Therapy
| 3/1/26
|
Oral Surgery
| 4/1/25 |
Organ and Tissue Transplantation
| 5/1/26
|
Orthodontics
| 4/1/25 |
Orthognathic Surgery
| 4/1/25 |
Orthotic Devices
| 4/1/25 |
Outpatient Surgery
| 4/1/25
|
Oxygen
| 4/1/25
|
Pain Management Programs
| 4/1/25
|
Physical Therapy
| 3/1/26
|
Podiatry/Podiatric Services
| 4/1/25
|
Pre-implantation Genetic Testing (PGT) – Infertility Related
| 3/1/26 |
Pre-implantation Genetic Testing (PGT) – Non-infertility Related
| 3/1/26 |
Private Duty Nursing
| 4/1/25
|
Prostate Procedures
| 4/1/25 |
Prosthetic Devices
| 1/1/26
|
Pulmonary Rehabilitation
| 4/1/25 |
Refractive Keratoplasty
| 4/1/25 |
Respiratory Therapy (Inhalation Therapy)
| 4/1/25
|
Seat Lift
| 4/1/25 |
Second Opinions
| 4/1/25 |
Sensory Evoked Potentials (SEP)
| 4/1/25 |
Skilled Nursing Facility (SNF)
| 4/1/25 |
Speech Therapy
| 3/1/26
|
Sterilizations
| 4/1/25
|
Synagis®
| 4/1/25
|
Temporomandibular Joint Disorder
| 4/1/25
|
Tobacco Cessation
| 4/1/25
|
Transgender Services
| 4/1/25
|
Ultraviolet Light Treatment for Psoriasis
| 4/1/25
|
Vision Screening/Routine Vision Care
| 4/1/25
|
Well Child Care
| 4/1/25
|
Wheelchairs
| 4/1/25
|
