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Medical Clinical Policy Bulletins

What's New in the Clinical Policy Bulletins

Clinical Policy Bulletins | Dental Policy Bulletins | Pharmacy Policy Bulletins

Additions, Revisions, Updates, and Deletions Sorted by Date

New:

May 17, 2013 - 0846 - Near-Infrared Vascular Imaging
May 17, 2013 - 0847 - Radiofrequency Ablation of the Renal Sympathetic Nerve for Hypertension
April 23, 2013 - 0845 - Carfilzomib (Kyprolis)
March 26, 2013 - 0843 - Focal Laser Ablation for the Treatment of Prostate Cancer
March 26, 2013 - 0844 - Fecal Microbiota Transplantation
March 19, 2013 - 0841 - Non-invasive Measurement of Advanced Glycation End-products in the Skin
February 15, 2013 - 0839 - Tofacitinib (Xeljanz)
February 15, 2013 - 0840 - Devices for Post-Operative Use Following Endoscopic Sinus Surgery
February 15, 2013 - 0842 - Ziv-Aflibercept (Zaltrap)
January 18, 2013 - 0837 - Shoulder Arthroplasty
January 18, 2013 - 0838 - Stem Cell Transplantation for Myelofibrosis

Revised:

May 17, 2013 - 0247 - Autologous Chondrocyte Implantation
May 17, 2013 - 0249 - Inflammatory Bowel Disease: Serologic Markers and Pharmacogenomic and Metabolic Assessment of Thiopurine Therapy
May 17, 2013 - 0251 - Dermabrasion, Chemical Peels, and Acne Surgery
May 17, 2013 - 0253 - Vocal Cord Paralysis/Insufficiency Treatments
May 17, 2013 - 0262 - External Counterpulsation (ECP)
May 17, 2013 - 0264 - Multiple Sclerosis
May 17, 2013 - 0268 - Liver and Other Neoplasms - Treatment Approaches
May 17, 2013 - 0269 - Breast Biopsy Procedures
May 14, 2013 - 0088 - Antepartum Fetal Surveillance
May 14, 2013 - 0142 - Breast Implant Removal
May 14, 2013 - 0226 - Hospitalization for the Initiation of Ketogenic Diet for the Treatment of Intractable Seizures
May 14, 2013 - 0227 - BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy
May 14, 2013 - 0229 - Iontophoresis
May 14, 2013 - 0234 - Chelation Therapy
May 14, 2013 - 0235 - Plantar Fasciitis Treatments
May 14, 2013 - 0238 - Chronic Vertigo
May 14, 2013 - 0241 - Extracorporeal Photochemotherapy (Photopheresis)
May 14, 2013 - 0244 - Wound Care
May 14, 2013 - 0245 - Tumor Chemosensitivity Assays
May 3, 2013 - 0670 - Xolair (Omalizumab)
April 30, 2013 - 0206 - Parenteral Immunoglobulins
April 30, 2013 - 0208 - Deep Brain Stimulation
April 30, 2013 - 0211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair
April 30, 2013 - 0213 - Gastroesophageal Reflux Disease (GERD): Treatment Devices
April 30, 2013 - 0214 - Cognitive Rehabilitation
April 30, 2013 - 0221 - Quantitative EEG (Brain Mapping)
April 30, 2013 - 0223 - Urinary Incontinence Treatments
April 30, 2013 - 0289 - Grid Monitoring and Intraoperative Electroencephalography
April 30, 2013 - 0404 - Interferons
April 30, 2013 - 0598 - Lung Transplantation
April 30, 2013 - 0697 - Intraoperative Electromyographic Monitoring
April 26, 2013 - 0179 - Viscosupplementation
April 26, 2013 - 0180 - Vertebral Axial Decompression
April 26, 2013 - 0181 - Evoked Potential Studies
April 26, 2013 - 0182 - Ventricular Remodeling Operation (Batista Procedure) and Surgical Ventricular Restoration (Dor Procedure)
April 26, 2013 - 0184 - Pulmonary Hypertension Treatments and Selected Indications of Prostanoids
April 26, 2013 - 0185 - Breast Reconstructive Surgery
April 26, 2013 - 0188 - Total Body Photography and Dermoscopy
April 26, 2013 - 0191 - Vagus Nerve Stimulation
April 26, 2013 - 0194 - Dorsal Column Stimulation
April 26, 2013 - 0195 - Erythropoiesis Stimulating Agents
April 26, 2013 - 0199 - Ultrasound for Pregnancy
April 26, 2013 - 0204 - Manipulation Under General Anesthesia
April 26, 2013 - 0205 - Phototherapy and Photochemotherapy (PUVA) for Skin Conditions
April 23, 2013 - 0171 - MRI of the Extremities
April 23, 2013 - 0172 - Hyperbaric Oxygen Therapy (HBOT)
April 23, 2013 - 0173 - Prothrombin Time (INR) Home Testing Devices
April 23, 2013 - 0175 - High-Frequency Pulsed Electromagnetic Stimulation
April 23, 2013 - 0177 - Helicobacter Pylori Infection Testing
April 23, 2013 - 0327 - Infertility
April 23, 2013 - 0421 - Breast Pumps
April 23, 2013 - 0443 - Cervical Cancer Screening and Diagnosis
April 23, 2013 - 0453 - Cervical Traction Devices
April 23, 2013 - 0594 - Visudyne (Verteporfin) Photodynamic Therapy
April 23, 2013 - 0657 - Tubal Sterilization
April 23, 2013 - 0684 - Cetuximab (Erbitux)
April 19, 2013 - 0002 - Oxygen
April 19, 2013 - 0035 - Influenza Vaccine
April 19, 2013 - 0084 - Ptosis Surgery
April 19, 2013 - 0130 - Computerized Corneal Topography
April 19, 2013 - 0131 - Clotting Factors
April 19, 2013 - 0132 - Biofeedback
April 19, 2013 - 0134 - Bone Mass Measurements
April 19, 2013 - 0135 - Acupuncture
April 19, 2013 - 0157 - Obesity Surgery
April 19, 2013 - 0161 - Infusion Pumps
April 19, 2013 - 0166 - Fetal Fibronectin, Inflammatory Biomarkers, and Salivary Estriol Testing for Preterm Labor
April 19, 2013 - 0168 - Tumor Scintigraphy
April 19, 2013 - 0170 - Growth Hormone (GH) and Growth Hormone Antagonists
March 26, 2013 - 0111 - Indocyanine Green Angiography
March 26, 2013 - 0113 - Botulinum Toxin
March 26, 2013 - 0115 - Varicella and Herpes Zoster Vaccines
March 26, 2013 - 0116 - Frenectomy or Frenotomy for Ankyloglossia
March 26, 2013 - 0388 - Complementary and Alternative Medicine
March 26, 2013 - 0729 - Diabetic Neuropathy: Selected Treatments
March 26, 2013 - 0779 - Plerixafor Injection (Mozobil)
March 26, 2013 - 0796 - Near-Infrared (NIR) Spectroscopy
March 22, 2013 - 0055 - Hematopoietic Colony-Stimulating Factors (CSFs)
March 22, 2013 - 0061 - Nutritional Support
March 22, 2013 - 0067 - Chest Physiotherapy and Airway Clearance Devices
March 22, 2013 - 0069 - Lymphedema
March 22, 2013 - 0071 - Positron Emission Tomography (PET)
March 22, 2013 - 0073 - Cardiac Event Monitors
March 22, 2013 - 0079 - Benign Prostatic Hypertrophy (BPH) Treatments
March 22, 2013 - 0094 - Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
March 22, 2013 - 0100 - Cryoablation
March 22, 2013 - 0107 - Chiropractic Services
March 19, 2013 - 0004 - Obstructive Sleep Apnea in Adults
March 19, 2013 - 0007 - Erectile Dysfunction
March 19, 2013 - 0008 - Color-Flow Doppler Echocardiography in Adults
March 19, 2013 - 0009 - Orthopedic Casts, Braces and Splints
March 19, 2013 - 0010 - Continuous Passive Motion (CPM) Machines
March 19, 2013 - 0011 - Electrical Stimulation for Pain
March 19, 2013 - 0016 - Back Pain - Invasive Procedures
March 19, 2013 - 0022 - Calcitriol and Paricalcitol Injections
March 19, 2013 - 0024 - Interleukin-2 (Aldesleukin, Proleukin, IL-2)
March 19, 2013 - 0025 - Automated Ambulatory Blood Pressure Monitoring
March 19, 2013 - 0028 - Temporomandibular Disorders
March 19, 2013 - 0031 - Cosmetic Surgery
March 19, 2013 - 0032 - Pulmonary Rehabilitation
March 19, 2013 - 0038 - Allergy and Hypersensitivity
March 19, 2013 - 0743 - Spinal Surgery: Laminectomy and Fusion
March 19, 2013 - 0827 - Electric Tumor Treatment Fields
February 15, 2013 - 0037 - Pneumococcal Vaccine
February 15, 2013 - 0270 - Proton Beam and Neutron Beam Radiotherapy
February 15, 2013 - 0352 - Tumor Markers
February 15, 2013 - 0404 - Interferons
February 15, 2013 - 0421 - Breast Pumps
February 15, 2013 - 0650 - Polymerase Chain Reaction Testing: Selected Indications
February 15, 2013 - 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization
February 15, 2013 - 0785 - Peripheral Artery Stents
February 15, 2013 - 0787 - Comparative Genomic Hybridization (CGH)
February 15, 2013 - 0804 - Denosumab (Prolia and Xgeva)
February 15, 2013 - 0817 - Propranolol for Infantile Hemangioma
February 4, 2013 - 0464 - Serum Marker Screening for Down Syndrome
February 1, 2013 - 0807 - Eculizumab (Soliris)
January 18, 2013 - 0091 - Endometrial Ablation
January 18, 2013 - 0140 - Genetic Testing
January 18, 2013 - 0356 - Meningococcal Vaccine
January 18, 2013 - 0653 - Diphtheria, Tetanus, and Pertussis Vaccines
January 18, 2013 - 0689 - Ocular Photoscreening
January 4, 2013 - 0179 - Viscosupplementation

Updated:

May 7, 2013 - 0174 - Pool Therapy, Aquatic Therapy or Hydrotherapy
May 7, 2013 - 0189 - Genetic Counseling
May 7, 2013 - 0190 - Stem Cells for Bone Marrow Transplant
May 7, 2013 - 0198 - Work Hardening Programs
May 7, 2013 - 0200 - Coumadin (Warfarin) to Heparin Conversion Before and After Elective Surgery
May 7, 2013 - 0201 - Skilled Home Health Care Nursing Services
May 7, 2013 - 0202 - Magnetic Resonance Spectroscopy (MRS)
May 7, 2013 - 0207 - Prolotherapy
May 7, 2013 - 0210 - Phonophoresis
May 7, 2013 - 0212 - Skeletal Analysis Systems
May 7, 2013 - 0215 - Lyme Disease and other Tick-Borne Diseases
May 7, 2013 - 0218 - Home Health Aides
May 7, 2013 - 0220 - Distraction Osteosynthesis
May 7, 2013 - 0225 - Maze Procedure
May 3, 2013 - 0160 - Lung Volume Reduction Surgery
May 3, 2013 - 0163 - Transmyocardial and Endovascular Laser Revascularization
May 3, 2013 - 0165 - Cardiac Catheter Ablation Procedures
May 3, 2013 - 0169 - Outpatient Medical Self-Care Programs
April 16, 2013 - 0126 - Contact Lenses and Eyeglasses
April 16, 2013 - 0127 - Home Uterine Activity Monitoring
April 16, 2013 - 0136 - Skilled Home Private Duty Nursing Care
April 16, 2013 - 0145 - Alpha 1-Antitrypsin Inhibitor Therapy
April 16, 2013 - 0147 - Reflex Sympathetic Dystrophy Diagnosis
April 16, 2013 - 0151 - Hippotherapy
April 16, 2013 - 0153 - Thalamotomy
April 16, 2013 - 0155 - Ribavirin (Virazole)
March 15, 2013 - 0049 - Nutritional Counseling
March 15, 2013 - 0059 - Peak Flow Meters
March 15, 2013 - 0062 - Burn Garments
March 15, 2013 - 0065 - Nebulizers
March 15, 2013 - 0078 - Learning Disabilities, Dyslexia, and Vision
March 15, 2013 - 0082 - Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans
March 15, 2013 - 0083 - Stereotactic Radiosurgery
March 15, 2013 - 0093 - Open Air, Low Field Strength, and Positional MRI Units
March 15, 2013 - 0095 - Orthognathic Surgery
March 15, 2013 - 0097 - External Breast Prosthesis
March 15, 2013 - 0105 - Magnetic Resonance Imaging (MRI) of the Breast
March 15, 2013 - 0106 - Fetal Echocardiograms
March 15, 2013 - 0112 - Surface Scanning and Macro Electromyography
March 15, 2013 - 0124 - General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services
March 8, 2013 - 0001 - Transrectal Ultrasound
March 8, 2013 - 0003 - Apnea Monitors for Infants
March 8, 2013 - 0005 - Septoplasty and Rhinoplasty
March 8, 2013 - 0019 - Holter Monitors
March 8, 2013 - 0020 - Injectable Medications
March 8, 2013 - 0021 - Cardiac Rehabilitation
March 8, 2013 - 0027 - Implantable Vas Deferens Occlusion Devices
March 8, 2013 - 0029 - Thermography
March 8, 2013 - 0034 - Aural Rehabilitation
March 8, 2013 - 0039 - Weight Reduction Medications and Programs
March 8, 2013 - 0046 - Routine Foot Care
March 8, 2013 - 0047 - Prenatal Care Provided by Primary Care Physicians
March 8, 2013 - 0048 - Hepatitis A Vaccine

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