Physician Clinical Coverage Policies
Files
1A-2.pdf
1A-2, Preventive Medicine Annual Health Assessment
1A-3.pdf
1A-3, Noninvasive Pulse Oximetry
1A-4.pdf
1A-4, Cochlear and Auditory Brainstem Implants
1A-5.pdf
1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
1A-6.pdf
1A-6, Invasive Electrical Bone Growth Stimulation
1A-7.pdf
1A-7, Neonatal and Pediatric Critical and Intensive Care Services
1A-8.pdf
1A-8, Hyperbaric Oxygenation Therapy
1A-9.pdf
1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
1A-11.pdf
1A-11, Extracorporeal Shock Wave Lithotripsy
1A-12.pdf
1A-12, Breast Surgeries
1A-13.pdf
1A-13, Ocular Photodynamic Therapy
1A-14.pdf
1A-14, Surgery for Ambiguous Genitalia
1A-15_0.pdf
1A-15, Surgery for clinically severe or Morbid Obesity
1A-16.pdf
1A-16, Surgery of the Lingual Frenulum
1A-17.pdf
1A-17, Stereotactic Pallidotomy
1A-19.pdf
1A-19, Transcranial Doppler Studies
1A-20.pdf
1A-20, Sleep Studies and Polysomnography Services
1A-21.pdf
1A-21, Endovascular Repair of Aortic Aneurysm
1A-22.pdf
Medically Necessary Circumcision
1A-23.pdf
1A-23, Physician Fluoride Varnish Services
1A-24.pdf
1A-24, Diabetes Outpatient Self-Management Education
1A-25.pdf
1A-25, Spinal Cord Stimulation
1A-26.pdf
1A-26, Deep Brain Stimulation
1A-27.pdf
1A-27, Electrodiagnostic Studies
1A-28.pdf
1A-28, Visual Evoked Potential (VEP)
1A-30.pdf
1A-30, Spinal Surgeries
1A-31.pdf
1A-31, Wireless Capsule Endoscopy
1A-32.pdf
1A-32, Tympanometry and Acoustic Reflex Testing
1A-33.pdf
1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
1A-34.pdf
1A-34, Dialysis Services
1A-36.pdf
1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
1A-38.pdf
1A-38, Special Services: After Hours
1A-39.pdf
1A-39, Routine Costs in Clinical Trial Services for Life Threatening Conditions
1A-40.pdf
1A-40, Fecal Microbiota Transplantation
1A-41.pdf
1A-41- Office Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone
1A-42.pdf
1A-42, Balloon Ostial Dilation
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