Insurer medical policies

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Continuing the Insurer medical policies list, 1000 records per page, after united-healthcare-2023r0111b.

1. united-healthcare-2023r0112aNonphysician Health Care Professionals Billing Evaluation and Management Codes Policy…
2. united-healthcare-2023r0112bNonphysician Health Care Professionals Billing Evaluation and Management Codes Policy…
3. united-healthcare-2023r0113aFrom-To Date Policy, Professional - Exchange
4. united-healthcare-2023r0113bFrom-To Date Policy, Professional - Reimbursement Policy - UnitedHealthcare Community Plan
5. united-healthcare-2023r0114aRobotic-Assisted-Surgery-Policy-Professional
6. united-healthcare-2023r0115aObservation and Discharge Policy, Professional - Exchange
7. united-healthcare-2023r0115bObservation and Discharge Policy, Professional
8. united-healthcare-2023r0116aOnce in a Lifetime Procedures Policy, Professional - Exchange
9. united-healthcare-2023r0117aWrong Surgical or Other Invasive Procedures Policy, Professional and Facility…
10. united-healthcare-2023r0118aOne or More Sessions Policy, Professional - Exchange
11. united-healthcare-2023r0119aProcedure to Modifier Policy, Professional - Reimbursement Policy - UnitedHealthcare®…
12. united-healthcare-2023r0119bProcedure to Modifier Policy, Professional - UnitedHealthcare Individual Exchange
13. united-healthcare-2023r0119eProcedure to Modifier Policy, Professional - Reimbursement Policy - UnitedHealthcare…
14. united-healthcare-2023r011aModifier Reference Policy, Professional - Exchange
15. united-healthcare-2023r0121aPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy…
16. united-healthcare-2023r0121bPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy…
17. united-healthcare-2023r0122aInappropriate Primary Diagnosis Codes Policy, Professional - Exchange
18. united-healthcare-2023r0122bInappropriate Primary Diagnosis Codes Policy, Professional - Reimbursement Policy…
19. united-healthcare-2023r0123aAmbulance Policy, Professional-Exchange
20. united-healthcare-2023r0124aServices and Modifiers Not Reimbursable to Healthcare Professionals Policy, Professional…
21. united-healthcare-2023r0125aMultiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and…
22. united-healthcare-2023r0126aPediatric and Neonatal Critical and Intensive Care Services Policy, Professional…
23. united-healthcare-2023r0127bProcedure and Place of Service Policy, Professional - Reimbursement Policy…
24. united-healthcare-2023r0127cProcedure and Place of Service Policy, Professional - Exchange
25. united-healthcare-2023r0128bReplacement Codes Policy, Professional - Exchange
26. united-healthcare-2023r0129aConsultation Services Policy, Professional - Exchange
27. united-healthcare-2023r012aInappropriate Primary Diagnosis Codes Policy, Professional - Reimbursement Policy…
28. united-healthcare-2023r3003aStandby Services Policy, Professional - Exchange
29. united-healthcare-2023r5000aAssistant-at-Surgery Services Policy, Professional - Exchange
30. united-healthcare-2023r5006aNonphysician Health Care Codes Policy, Professional - Reimbursement Policy…
31. united-healthcare-2023r5007aEvaluation and Management (E/M) Policy, Professional
32. united-healthcare-2023r5008aIntraoperative Neuromonitoring Policy, Professional - Exchange
33. united-healthcare-2023r5009aAdvanced Practice Health Care Provider Policy, Professional - Exchange
34. united-healthcare-2023r5010aRespiratory Viral Panel Testing Policy, Professional and Facility - Exchange
35. united-healthcare-2023r5011aOutpatient Hospital Maximum Frequency Per Day Policy, Facility - Reimbursement Policy…
36. united-healthcare-2023r5011bOutpatient Hosptial Maximum Frequency Per Day Policy, Facility- Exchange
37. united-healthcare-2023r5012aOutpatient Hospital Add-on Codes Policy, Facility - Reimbursement Policy…
38. united-healthcare-2023r5019aDevice, Implant, and Skin Substitute Policy, Facility - Reimbursement Policy…
39. united-healthcare-2023r5021aInpatient Unacceptable Principal Diagnosis Policy, Facility - Reimbursement Policy…
40. united-healthcare-2023r5025aServices Incident-to a Supervising Health Care Provider Policy, Professional…
41. united-healthcare-2023r5026aServices by Residents, Interns and Medical Students Policy, Professional - Reimbursement…
42. united-healthcare-2023r5031aTelehealth Policy, Facility - Exchange
43. united-healthcare-2023r6002aNational Drug Code (NDC) Requirement Policy, Professional and Facility - Reimbursement…
44. united-healthcare-2023r6002bNational Drug Code (NDC) Requirement Policy, Facility and Professional - Exchange
45. united-healthcare-2023r6002cNational Drug Code (NDC) Requirement Policy, Professional and Facility - Reimbursement…
46. united-healthcare-2023r6003aEmergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy…
47. united-healthcare-2023r6004aDiscarded Drugs and Biologicals Policy, Professional and Facility - Exchange
48. united-healthcare-2023r6005aDrug Testing Policy, Professional-Exchange
49. united-healthcare-2023r6007aEmergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy…
50. united-healthcare-2023r6009aMolecular Pathology Policy, Professional - Reimbursement Policy - UnitedHealthcare…
51. united-healthcare-2023r6013aOutpatient Hospital Observation Policy, Facility - Reimbursement Policy - UnitedHealthcare…
52. united-healthcare-2023r6031aOutpatient Hospital Observation Policy, Facility - Exchange
53. united-healthcare-2023r7013aAdd-on Codes Policy, Facility - Exchange
54. united-healthcare-2023r7101cUnlisted Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
55. united-healthcare-2023r7102eNon Covered and Covered Codes Policy, Professional - Reimbursement Policy…
56. united-healthcare-2023r7107aEmergency Room Services Policy, Professional (Tennessee) - Reimbursement Policy…
57. united-healthcare-2023r7108fProcedure to Place of Service Policy, Professional - Reimbursement Policy…
58. united-healthcare-2023r7109aVaccines for Children Policy, Professional - Reimbursement Policy - UnitedHealthcare…
59. united-healthcare-2023r7111aIncontinence Supplies Policy, Professional - Reimbursement Policy - UnitedHealthcare…
60. united-healthcare-2023r7112bObstetrical Ultrasound Policy, Professional - Reimbursement Policy - UnitedHealthcare…
61. united-healthcare-2023r7117fMedically Unlikely Edits (MUE) Policy, Professional and Facility - Reimbursement Policy…
62. united-healthcare-2023r7121aGender to Diagnosis Code and Procedure Policy, Professional - Reimbursement Policy…
63. united-healthcare-2023r7122aCesarean Delivery Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
64. united-healthcare-2023r7125aSexually Transmitted Infection Testing Policy, Professional and Facility - Exchange
65. united-healthcare-2023r7126bNew Jersey Early Elective Delivery Policy, Professional and Facility - Reimbursement…
66. united-healthcare-2023r7128aServices by Residents, Interns and Medical Students Policy, Professional - Reimbursement…
67. united-healthcare-2023r8100aClinical Diagnostic Lab Policy, Professional-Exchange
68. united-healthcare-2023r9001aDiscarded Drugs and Biologicals, Professional - Reimbursement Policy - UnitedHealthcare…
69. united-healthcare-2023r9007aAdd-on Codes Policy, Professional - Reimbursement Policy - UnitedHealthcare Medicare…
70. united-healthcare-2023r9008aAnesthesia Services Policy, Professional - Reimbursement Policy - UnitedHealthcare…
71. united-healthcare-2023r9015aIncreased Procedural Services Policy, Professional - Reimbursement Policy…
72. united-healthcare-2023r9022aMultiple Procedure Payment Reduction (MPPR) for Therapy Services, Professional…
73. united-healthcare-2023r9023aMultiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and…
74. united-healthcare-2023r9025aNon-Chemotherapy Injection and Infusion Services, Professional - Reimbursement Policy…
75. united-healthcare-2023r9028aOnce in a Lifetime Procedures, Professional - Reimbursement Policy - UnitedHealthcare…
76. united-healthcare-2023r9031aProfessional/Technical Component, Professional - Reimbursement Policy - UnitedHealthcare…
77. united-healthcare-2023r9036aStandby Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Medicare…
78. united-healthcare-2023r9041aIntraoperative Neuromonitoring Policy, Professional - Reimbursement Policy…
79. united-healthcare-2023r9050aHearing Aids Policy, Professional - Exchange
80. united-healthcare-2023r9051aOutpatient Hospital Inappropriate Primary Diagnosis Codes Policy Facility
81. united-healthcare-2023r9052aHabilitative and Rehabilitative Services Policy Professional and Facility…
82. united-healthcare-2023r9054aServices Incident-to a Supervising Health Care Provider Policy, Professional - Exchange
83. united-healthcare-2023r9055aServices by Residents, Interns and Medical Students Policy, Professional - Reimbursement…
84. united-healthcare-2023r9057aInpatient Readmission Review Policy, Facility - Exchange
85. united-healthcare-2023r9062aModifier Policy, Facility - Exchange
86. Genetic Testing for Hereditary Cancer - Commercial and Individual Exchange Medical Policy
87. united-healthcare-2023t0072wVisual Information Processing Evaluation and Orthoptic and Vision Therapy - Commercial and…
88. Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Commercial…
89. Sleep Studies - Commercial and Individual Exchange Medical Policy
90. Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes - Commercial and…
91. Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable…
92. Total Artificial Disc Replacement for the Spine - Commercial and Individual Exchange…
93. Glaucoma Surgical Treatments - Commercial and Individual Exchange Medical Policy
94. united-healthcare-2023t0548zHepatitis Screening - Commercial and Individual Exchange Medical Policy
95. united-healthcare-2023t0580mGender Dysphoria Treatment - Commercial and Individual Exchange Medical Policy
96. united-healthcare-2023t0587lPharmacogenetic Panel Testing - Commercial and Individual Exchange Medical Policy
97. united-healthcare-2023t0588yMolecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment…
98. united-healthcare-2023t0602iLower Extremity Endovascular Procedures - Commercial and Individual Exchange Medical…
99. united-healthcare-2023t0603dEnvironmental Allergen Immunotherapy – Commercial Medical Policy
100. united-healthcare-2023t0609jCatheter Ablation for Atrial Fibrillation - Commercial and Individual Exchange Medical…
101. united-healthcare-2023t0611cStereotactic Body Radiation Therapy and Stereotactic Radiosurgery - Commercial and…
102. united-healthcare-2023t0613dRadiation Therapy: Fractionation, Image-Guidance, and Special Services - Commercial and…
103. united-healthcare-2023t0618fProstate Surgeries and Interventions - Commercial and Individual Exchange Medical Policy
104. united-healthcare-2023t0621fSacroiliac Joint Interventions - Commercial and Individual Exchange Medical Policy
105. united-healthcare-2023t0628cObstetrical Ultrasound – Commercial Medical Policy
106. united-healthcare-2023t0629cPercutaneous Neuroablation for Pancreatic Cancer Pain, Severe Cancer Pain, and Trigeminal…
107. Neonatal Fc Receptor Blockers (Rystiggo®, Vyvgart®, & Vyvgart® Hytrulo) - Commercial…
108. Qalsody® (Tofersen) - Commercial Medical Benefit Drug Policy
109. Rebyota® (Fecal Microbiota, Live-Jslm) - Commercial Medical Benefit Drug Policy
110. Elevidys™ (Delandistrogene Moxparvovec-Rokl) - Commercial Medical Benefit Drug Policy
111. united-healthcare-2024d0057qBuprenorphine (Brixadi® & Sublocade®) - Commercial Medical Benefit Drug Policy
112. united-healthcare-2024d0118eOphthalmologic Complement Inhibitors - Commercial Medical Benefit Drug Policy
113. united-healthcare-2024d0120gGene Therapies for Hemophilia B - Commercial Medical Benefit Drug Policy
114. united-healthcare-2024d0122cBriumvi® (Ublituximab-Xiiy) - Commercial Medical Benefit Drug Policy
115. united-healthcare-2024d0127dVyjuvek® (Beramagene Geperpavec-Svdt) - Commercial Medical Benefit Drug Policy
116. united-healthcare-2024d0128bVeopoz® (Pozelimab-Bbfg) - Commercial Medical Benefit Drug Policy
117. united-healthcare-2024d0129aOmvoh® (Mirikizumab-Mrkz) - Commercial Medical Benefit Drug Policy
118. united-healthcare-2024d0130aKisunla™ (Donanemab-Azbt) - Commercial Medical Benefit Drug Policy
119. united-healthcare-2024d0131bAdzynma (ADAMTS13, Recombinant-Krhn) - Commercial Medical Benefit Drug Policy
120. united-healthcare-2024d0132aCosentyx® (Secukinumab) - Commercial Medical Benefit Drug Policy
121. united-healthcare-2024f7002aProvider Preventable Conditions: Health Care Acquired Conditions and Present on Admission…
122. united-healthcare-2024f7016cObservation Services Policy, Facility - Reimbursement Policy - UnitedHealthcare Community…
123. united-healthcare-2024f7023aModifier Policy, Facility - Reimbursement Policy - UnitedHealthcare Community Plan
124. united-healthcare-2024f7024cDevice and Skin Substitute Policy, Facility - Reimbursement Policy - UnitedHealthcare…
125. united-healthcare-2024f7025bOutpatient Medical Visits and Trauma Activation Policy, Facility - UnitedHealthcare…
126. Hospital Inclusive Charges Policy, Facility - Reimbursement Policy - UnitedHealthcare…
127. united-healthcare-2024r0004aNew Patient Visit Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
128. united-healthcare-2024r0014eLaboratory Services Policy, Professional-Reimbursement Policy - UnitedHealthcare Community…
129. united-healthcare-2024r0023bBilateral Procedures Policy, Professional - Reimbursement Policy - UnitedHealthcare…
130. united-healthcare-2024r0038aMicrosurgery Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial and…
131. united-healthcare-2024r0060nMaximum Frequency Per Day Policy, Professional - Reimbursement Policy - UnitedHealthcare…
132. united-healthcare-2024r0064bObstetrical Services Policy, Professional - Reimbursement Policy - UnitedHealthcare…
133. united-healthcare-2024r0065aReduced Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
134. united-healthcare-2024r0071eAdd-on Codes Policy, Professional - Reimbursement Policy - UnitedHealthcare Community Plan
135. united-healthcare-2024r0098aPhysical Medicine & Rehabilitation: PT, OT and Evaluation and Management Policy…
136. united-healthcare-2024r0100fB Bundle Codes Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
137. united-healthcare-2024r0104dContrast and Radiopharmaceutical Materials Policy, Professional - Reimbursement Policy…
138. united-healthcare-2024r0106aSplit Surgical Package Policy, Professional - Reimbursement Policy - UnitedHealthcare…
139. united-healthcare-2024r0107aT Status Codes Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
140. united-healthcare-2024r0111cMolecular Pathology Policy, Professional and Facility - Reimbursement Policy…
141. united-healthcare-2024r0111dModifier Reference Policy, Professional - Reimbursement Policy - UnitedHealthcare…
142. united-healthcare-2024r0112aNonphysician Health Care Professionals Billing Evaluation and Management Codes Policy…
143. united-healthcare-2024r0114bRobotic Assisted Surgery Policy, Professional - Reimbursement Policy - UnitedHealthcare…
144. united-healthcare-2024r0116bOnce in a Lifetime Procedures Policy, Professional - Reimbursement Policy…
145. united-healthcare-2024r0124aServices and Modifiers Not Reimbursable to Healthcare Professionals Policy, Professional…
146. united-healthcare-2024r0126aPediatric and Neonatal Critical and Intensive Care Services Policy, Professional…
147. united-healthcare-2024r0129aConsultation Services Policy, Professional - Reimbursement Policy - UnitedHealthcare…
148. united-healthcare-2024r3003aStandby Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial…
149. united-healthcare-2024r5030bModifier Reduction Policy, Professional - Reimbursement Policy - UnitedHealthcare…
150. united-healthcare-2024r5031bTelehealth Policy, Facility - Reimbursement Policy - UnitedHealthcare Commercial and…
151. united-healthcare-2024r5032dAge-Based Codes Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial…
152. united-healthcare-2024r5033aAnatomical Modifier Requirement Policy, Professional - Reimbursement Policy…
153. united-healthcare-2024r5034aDiagnosis Code Requirement Policy, Professional and Facility - Reimbursement Policy…
154. united-healthcare-2024r5035bHospital Inclusive Charges Policy, Facility - Reimbursement Policy - UnitedHealthcare…
155. united-healthcare-2024r5036bHome Health Services Policy, Professional - Reimbursement Policy - UnitedHealthcare…
156. united-healthcare-2024r5061aOutpatient Rehabilitation Therapy Service Policy, Facility - Reimbursement Policy…
157. united-healthcare-2024r6004bDiscarded Drugs and Biologicals Policy, Professional and Facility Policy - Reimbursement…
158. united-healthcare-2024r6005bDrug Testing Policy, Professional - Reimbursement Policy - UnitedHealthcare Community Plan
159. united-healthcare-2024r6011bOutpatient Medical Visits and Trauma Activation Policy, Facility - Reimbursement Policy…
160. united-healthcare-2024r7101cUnlisted Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
161. united-healthcare-2024r7103aOrthotics (L3000) Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
162. united-healthcare-2024r7108mProcedure to Place of Service Policy, Professional - Reimbursement Policy…
163. united-healthcare-2024r7117eMedically Unlikely Edits Policy Professional and Facility - Reimbursement Policy…
164. united-healthcare-2024r7123aVitamin D Testing Policy, Professional - Reimbursement Policy - UnitedHealthcare Community…
165. united-healthcare-2024r7130bAnatomical Modifier Requirement Policy, Professional - Reimbursement Policy…
166. united-healthcare-2024r7131bDiagnosis Code Requirement Policy, Professional and Facility - Reimbursement Policy…
167. united-healthcare-2024r7132bHome Health Services Policy Professional - Reimbursement Policy - UnitedHealthcare…
168. united-healthcare-2024r7133aTelehealth/Virtual Health Policy, Professional and Facility - Reimbursement Policy…
169. united-healthcare-2024r9013aGlobal Days Policy, Professional - UnitedHealthcare Medicare Advantage Reimbursement…
170. united-healthcare-2024r9050aHearing Aids Policy, Professional - UnitedHealthcare Individual Exchange
171. united-healthcare-2024r9064aDiagnosis Code Requirement Policy, Professional and Facility - Reimbursement Policy…
172. united-healthcare-2024r9065aHospital Inclusive Charges Policy, Facility - UnitedHealthcare Medicare Advantage…
173. united-healthcare-2024r9066aAnatomical Modifier Requirement Policy, Professional - Reimbursement Policy…
174. united-healthcare-2024r9067aHome Health Services Policy, Professional and Facility - Reimbursement Policy…
175. united-healthcare-2024t0445xTransarterial Radioembolization (TARE)/ Selective Internal Radiation Therapy (SIRT) for…
176. united-healthcare-2024t0571pSinus Surgeries and Interventions - Commercial and Individual Exchange Medical Policy
177. united-healthcare-2024t0630dSacral Nerve Stimulation for Urinary and Fecal Indications - Commercial and Individual…
178. united-healthcare-2024t0638cInterspinous Fusion and Decompression Devices - Commercial and Individual Exchange Medical…
179. united-healthcare-2024t0639dSpinal Fusion and Decompression - Commercial and Individual Exchange Medical Policy
180. united-healthcare-2024t0640cMinimally Invasive Spine Surgery Procedures - Commercial and Individual Exchange Medical…
181. united-healthcare-2024t0641cUpper Extremity Prosthetic Devices - Commercial and Individual Exchange Medical Policy
182. united-healthcare-2024t0644iCategory III Codes - Commercial and Individual Exchange Medical Policy
183. united-healthcare-2024t0645eLower Extremity Prosthetics - Commercial and Individual Exchange Medical Policy
184. united-healthcare-2024t0646cCorneal Collagen Cross-Linking - Commercial and Individual Exchange Medical Policy
185. united-healthcare-2024t0647cFecal Microbiota Transplantation - Commercial and Individual Exchange Medical Policy
186. united-healthcare-2024t0648cTransanal Minimally Invasive Surgical Procedures - Commercial and Individual Exchange…
187. united-healthcare-2024t0650aInjectable Dermal Fillers and Bulking Agents - Commercial and Individual Exchange Medical…
188. united-healthcare-2024t0651aElectroretinography - Commercial and Individual Exchange Medical Policy
189. united-healthcare-2024t0652aMolecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment…
190. united-healthcare-2024t0653aMolecular Oncology Companion Diagnostic Testing - Commercial and Individual Exchange…
191. united-healthcare-2025d0043wTocilizumab (Actemra®, Tofidence™, & Tyenne®) Injection for Intravenous Infusion…
192. united-healthcare-2025d0134aTremfya® (Guselkumab) - Commercial Medical Benefit Drug Policy
193. united-healthcare-2025r5038aRadiation Therapy Planning, Dosimetry, Simulation/Devices and Management Policy…
194. united-healthcare-2025r7132aRadiation Therapy Planning, Dosimetry, Simulation/Devices and Management Policy…
195. united-healthcare-2025r7135aMolecular Pathology Policy, Professional and Facility - Reimbursement Policy…
196. united-healthcare-2025r9068aRadiation Therapy Planning, Dosimetry, Simulation/Devices and Management Policy…
197. united-healthcare-2025t0653dFDA Cleared or Approved Companion Diagnostic Testing - Commercial and Individual Exchange…
198. united-healthcare-2025t0660bOcular Photoscreening - Commercial and Individual Exchange Medical Policy
199. united-healthcare-496Medicare Chiropractic Services - Clinical Guideline
200. united-healthcare-497Medicare Outpatient Skilled Therapy PT OT ST - Clinical Guideline
201. Succeeding Carrier for Inpatient Admissions - Oxford Administrative Policy
202. Clinical Trials - Oxford Clinical Policy
203. Site of Service Differential - Oxford Administrative Policy
204. Omnibus Codes - Oxford Clinical Policy
205. Participating Providers Using Non-Participating Providers Protocol - Oxford Administrative…
206. Accreditation Requirements for Radiology Services - Oxford Administrative Policy
207. Wigs - Oxford Administrative Policy
208. Hospital Services: Observation and Inpatient - Oxford Clinical Policy
209. Upper Extremity Prosthetic Devices - Oxford Clinical Policy
210. Lower Extremity Prosthetics - Oxford Clinical Policy
211. Manipulative Therapy - Oxford Clinical Policy
212. Manipulation Under Anesthesia - Oxford Clinical Policy
213. Transcranial Magnetic Stimulation - Oxford Clinical Policy
214. Neuropsychological Testing Under the Medical Benefit - Oxford Clinical Policy
215. united-healthcare-bip001-nAbortions: CA - UnitedHealthcare West Benefit Interpretation Policy
216. united-healthcare-bip002-lAbortions: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
217. united-healthcare-bip003-mAllergy Testing and Injections: CA - UnitedHealthcare West Benefit Interpretation Policy
218. united-healthcare-bip004-lAllergy Testing and Injections: OK, OR, TX, WA - UnitedHealthcare West Benefit…
219. united-healthcare-bip005-nAmbulance Transportation: CA - UnitedHealthcare West Benefit Interpretation Policy
220. united-healthcare-bip006-kAmbulance Transportation: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
221. united-healthcare-bip009-kAttention Deficit Hyperactivity Disorder (ADHD): CA - UnitedHealthcare West Benefit…
222. united-healthcare-bip010-jAttention Deficit Hyperactivity Disorder (ADHD): OK, OR, TX, WA - UnitedHealthcare West…
223. united-healthcare-bip011-jPervasive Developmental Disorder and Autism Spectrum Disorder: TX - UnitedHealthcare West…
224. united-healthcare-bip013-lBiofeedback: CA - UnitedHealthcare West Benefit Interpretation Policy
225. united-healthcare-bip014-kBiofeedback: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
226. united-healthcare-bip015-lBlood and Blood Products: CA - UnitedHealthcare West Benefit Interpretation Policy
227. united-healthcare-bip016-kBlood and Blood Products: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
228. united-healthcare-bip017-oCardiac Pacemakers and Defibrillators: CA - UnitedHealthcare West Benefit Interpretation…
229. united-healthcare-bip018-pCardiac Pacemakers and Defibrillators: OK, OR, TX, WA - UnitedHealthcare West Benefit…
230. united-healthcare-bip023-oContinuity of Care: CA - UnitedHealthcare West Benefit Interpretation Policy
231. united-healthcare-bip024-nContinuity of Care: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
232. united-healthcare-bip025-mChemotherapy: CA - UnitedHealthcare West Benefit Interpretation Policy
233. united-healthcare-bip026-lChemotherapy: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
234. united-healthcare-bip027-mClinical Trials: CA - UnitedHealthcare West Benefit Interpretation Policy
235. united-healthcare-bip028-jClinical Trials: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
236. united-healthcare-bip029-lComplementary and Alternative Medicine: CA - UnitedHealthcare West Benefit Interpretation…
237. united-healthcare-bip030-kComplementary and Alternative Medicine: OK, OR, TX, WA - UnitedHealthcare West Benefit…
238. united-healthcare-bip031-lCourt, Attorney, or Agency Requested Services: CA - UnitedHealthcare West Benefit…
239. united-healthcare-bip032-kCourt, Attorney, or Agency Requested Services: OK, OR, TX, WA - UnitedHealthcare West…
240. united-healthcare-bip033-kDental Care and Oral Surgery: CA - UnitedHealthcare West Benefit Interpretation Policy
241. united-healthcare-bip034-kDental Care and Oral Surgery: OK, OR, TX, WA - UnitedHealthcare West Benefit…
242. united-healthcare-bip035-kChemical Dependency/Substance Abuse Detoxification: CA - UnitedHealthcare West Benefit…
243. united-healthcare-bip036-kChemical Dependency/Substance Abuse Detoxification: OK, OR, TX, WA - UnitedHealthcare West…
244. united-healthcare-bip037-mDevelopmental Delay and Learning Disabilities: CA - UnitedHealthcare West Benefit…
245. united-healthcare-bip038-kDevelopmental Delay and Learning Disabilities: OK, OR, TX, WA - UnitedHealthcare West…
246. united-healthcare-bip042-lDiabetic Management, Services and Supplies: CA - UnitedHealthcare West Benefit…
247. united-healthcare-bip043-kDiabetic Management, Services and Supplies: OK, OR, TX, WA - UnitedHealthcare West Benefit…
248. united-healthcare-bip044-mDialysis Services: CA - UnitedHealthcare West Benefit Interpretation Policy
249. united-healthcare-bip045-lDialysis Services: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
250. united-healthcare-bip048-mDurable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot…
251. united-healthcare-bip049-lDurable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot…
252. united-healthcare-bip055-mEducational Programs for Members: CA - UnitedHealthcare West Benefit Interpretation Policy
253. united-healthcare-bip056-lEducational Programs for Members: OK, OR, TX, WA - UnitedHealthcare West Benefit…
254. united-healthcare-bip057-mEmergency and Urgent Services: CA - UnitedHealthcare West Benefit Interpretation Policy
255. united-healthcare-bip058-jEmergency and Urgent Services: OK, OR, TX, WA - UnitedHealthcare West Benefit…
256. united-healthcare-bip059-kExperimental and Investigational Services: CA - UnitedHealthcare West Benefit…
257. united-healthcare-bip060-jExperimental and Investigational Services: OK, OR, TX, WA - UnitedHealthcare West Benefit…
258. united-healthcare-bip064-mFamily Planning: Contraception and Sterilization: CA - UnitedHealthcare West Benefit…
259. united-healthcare-bip064-nContraception and Sterilization: CA - UnitedHealthcare West Benefit Interpretation Policy
260. united-healthcare-bip065-pFamily Planning: Contraception and Sterilization: OK, OR, TX, WA - UnitedHealthcare West…
261. united-healthcare-bip065-qContraception and Sterilization: OK, OR, TX, WA - UnitedHealthcare West Benefit…
262. united-healthcare-bip066-lFamily Planning: Infertility Services: OK, OR, TX, WA - UnitedHealthcare West Benefit…
263. united-healthcare-bip067-oFamily Planning: Infertility Services: CA - UnitedHealthcare West Benefit Interpretation…
264. united-healthcare-bip069-mFoot Care and Podiatry Services: CA - UnitedHealthcare West Benefit Interpretation Policy
265. united-healthcare-bip070-lFoot Care and Podiatry Services: OK, OR, TX, WA - UnitedHealthcare West Benefit…
266. united-healthcare-bip071-mGenetic Testing: CA - UnitedHealthcare West Benefit Interpretation Policy
267. united-healthcare-bip072-mGenetic Testing: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
268. united-healthcare-bip073-lHearing Services: CA - UnitedHealthcare West Benefit Interpretation Policy
269. united-healthcare-bip074-lHearing Services: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
270. united-healthcare-bip075-mHome Health Care: CA - UnitedHealthcare West Benefit Interpretation Policy
271. united-healthcare-bip076-kHome Health Care: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
272. united-healthcare-bip077-nHospice: CA - UnitedHealthcare West Benefit Interpretation Policy
273. united-healthcare-bip078-lHospice: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
274. united-healthcare-bip081-lHospital Services (Inpatient and Outpatient): CA - UnitedHealthcare West Benefit…
275. united-healthcare-bip082-lHospital Services (Inpatient and Outpatient): OK, OR, TX, WA - UnitedHealthcare West…
276. united-healthcare-bip085-lImmunizations/Vaccinations: CA - UnitedHealthcare West Benefit Interpretation Policy
277. united-healthcare-bip086-lImmunizations/Vaccinations: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
278. united-healthcare-bip091-nMaternity and Newborn Care: CA - UnitedHealthcare West Benefit Interpretation Policy
279. united-healthcare-bip092-lMaternity and Newborn Care: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
280. united-healthcare-bip096-lMedical Necessity: CA - UnitedHealthcare West Benefit Interpretation Policy
281. united-healthcare-bip097-kMedical Necessity: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
282. united-healthcare-bip098-nMedications and Off-Label Drugs: CA - UnitedHealthcare West Benefit Interpretation Policy
283. united-healthcare-bip099-kMedications and Off-Label Drugs: OK, OR, TX, WA - UnitedHealthcare West Benefit…
284. united-healthcare-bip100-kInpatient and Outpatient Mental Health: CA - UnitedHealthcare West Benefit Interpretation…
285. united-healthcare-bip101-kInpatient and Outpatient Mental Health: OK, OR, TX, WA - UnitedHealthcare West Benefit…
286. united-healthcare-bip106-mServices/Complications Related to Non-Covered Services: CA - UnitedHealthcare West Benefit…
287. united-healthcare-bip107-lServices/Complications Related to Non-Covered Services: OK, OR, TX, WA - UnitedHealthcare…
288. united-healthcare-bip115-mTreatment of Extreme Obesity: CA - UnitedHealthcare West Benefit Interpretation Policy
289. united-healthcare-bip116-mTreatment of Extreme Obesity: OK, OR, TX, WA - UnitedHealthcare West Benefit…
290. united-healthcare-bip125-mPain Management: CA - UnitedHealthcare West Benefit Interpretation Policy
291. united-healthcare-bip126-jPain Management: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
292. united-healthcare-bip127-lAutism Spectrum Disorder: CA - UnitedHealthcare West Benefit Interpretation Policy
293. united-healthcare-bip128-jPervasive Developmental Disorder and Autism Spectrum Disorder: OK - UnitedHealthcare West…
294. united-healthcare-bip129-jPervasive Developmental Disorder and Autism Spectrum Disorder: WA - UnitedHealthcare West…
295. united-healthcare-bip130-kAutism Spectrum Disorder: OR - UnitedHealthcare West Benefit Interpretation Policy
296. united-healthcare-bip131-mPhysician Services: Primary Care and Specialist Visits: CA - UnitedHealthcare West Benefit…
297. united-healthcare-bip132-lPhysician Services: Primary Care and Specialist Visits: OK, OR, TX, WA - UnitedHealthcare…
298. united-healthcare-bip133-nPreventive Care Services: CA - UnitedHealthcare West Benefit Interpretation Policy
299. united-healthcare-bip134-sPreventive Care Services: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
300. united-healthcare-bip135-kDiagnostic and Therapeutic Radiology Services: CA - UnitedHealthcare West Benefit…
301. united-healthcare-bip136-kDiagnostic and Therapeutic Radiology Services: OK, OR, TX, WA - UnitedHealthcare West…
302. united-healthcare-bip138-pCardiac Rehabilitation Services - Outpatient: CA - UnitedHealthcare West Benefit…
303. united-healthcare-bip139-oCardiac Rehabilitation Services - Outpatient: OK, OR, TX, WA - UnitedHealthcare West…
304. united-healthcare-bip140-lChemical Dependency/Substance Abuse Rehabilitation: CA - UnitedHealthcare West Benefit…
305. united-healthcare-bip141-mChemical Dependency/Substance Abuse Rehabilitation: OK, OR, TX, WA - UnitedHealthcare West…
306. united-healthcare-bip142-kCognitive Rehabilitation: CA - UnitedHealthcare West Benefit Interpretation Policy
307. united-healthcare-bip143-jCognitive Rehabilitation: OK - UnitedHealthcare West Benefit Interpretation Policy
308. united-healthcare-bip143-kCognitive Rehabilitation: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
309. united-healthcare-bip144-jCognitive Rehabilitation: TX - UnitedHealthcare West Benefit Interpretation Policy
310. united-healthcare-bip145-jCognitive Rehabilitation: WA - UnitedHealthcare West Benefit Interpretation Policy
311. united-healthcare-bip146-jCognitive Rehabilitation: OR - UnitedHealthcare West Benefit Interpretation Policy
312. united-healthcare-bip147-pRehabilitation Services (Physical, Occupational, and Speech Therapy): CA…
313. united-healthcare-bip148-oRehabilitation Services (Physical, Occupational, and Speech Therapy): OK, OR, TX, WA…
314. united-healthcare-bip156-kMember Initiated Second and Third Opinion: CA - UnitedHealthcare West Benefit…
315. united-healthcare-bip157-kMember Initiated Second and Third Opinion: OK, OR, TX, WA - UnitedHealthcare West Benefit…
316. united-healthcare-bip158-mServices While Confined/Incarcerated: CA - UnitedHealthcare West Benefit Interpretation…
317. united-healthcare-bip160-mServices While Confined/Incarcerated: OK, OR, TX, WA - UnitedHealthcare West Benefit…
318. united-healthcare-bip161-lSexual Dysfunction: CA - UnitedHealthcare West Benefit Interpretation Policy
319. united-healthcare-bip162-kSexual Dysfunction: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation Policy
320. united-healthcare-bip163-lSkilled Nursing Facility (SNF): Skilled Nursing Facility (SNF) Care: CA - UnitedHealthcare…
321. united-healthcare-bip164-kSkilled Nursing Facility (SNF): Skilled Nursing Facility (SNF) Care: OK, OR, TX, WA…
322. united-healthcare-bip167-nShoes and Foot Orthotics: CA - UnitedHealthcare West Benefit Interpretation Policy
323. united-healthcare-bip168-mShoes and Foot Orthotics: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
324. united-healthcare-bip169-mCosmetic, Reconstructive, or Plastic Surgery: CA - UnitedHealthcare West Benefit…
325. united-healthcare-bip170-lCosmetic, Reconstructive, or Plastic Surgery: OK - UnitedHealthcare West Benefit…
326. united-healthcare-bip170-mCosmetic, Reconstructive, or Plastic Surgery: OK, OR, TX, WA - UnitedHealthcare West…
327. united-healthcare-bip171-lCosmetic, Reconstructive, or Plastic Surgery: TX - UnitedHealthcare West Benefit…
328. united-healthcare-bip172-lCosmetic, Reconstructive, or Plastic Surgery: WA - UnitedHealthcare West Benefit…
329. united-healthcare-bip173-lCosmetic, Reconstructive, or Plastic Surgery: OR - UnitedHealthcare West Benefit…
330. united-healthcare-bip176-lPost Mastectomy Surgery: CA - UnitedHealthcare West Benefit Interpretation Policy
331. united-healthcare-bip177-kPost Mastectomy Surgery: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
332. united-healthcare-bip181-kTelehealth and Virtual Care Services: CA - UnitedHealthcare West Benefit Interpretation…
333. united-healthcare-bip182-lTelehealth and Virtual Care Services: OK, OR, TX, WA - UnitedHealthcare West Benefit…
334. united-healthcare-bip183-mTreatment of Temporomandibular Joint (TMJ) Disorders: CA - UnitedHealthcare West Benefit…
335. united-healthcare-bip184-lTreatment of Temporomandibular Joint (TMJ) Disorders: OK, OR, TX, WA - UnitedHealthcare…
336. united-healthcare-bip185-sGender Dysphoria (Gender Identity Disorder) Treatment (for California Only): CA…
337. united-healthcare-bip186-oTransplantation Services: CA - UnitedHealthcare West Benefit Interpretation Policy
338. united-healthcare-bip187-lTransplantation Services: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
339. united-healthcare-bip189-mVeteran's Administration (VA): CA - UnitedHealthcare West Benefit Interpretation Policy
340. united-healthcare-bip190-lVeteran's Administration (VA): OK, OR, TX, WA - UnitedHealthcare West Benefit…
341. united-healthcare-bip193-mWeight Gain or Weight Loss Programs: CA - UnitedHealthcare West Benefit Interpretation…
342. united-healthcare-bip194-lWeight Gain or Weight Loss Programs: OK, OR, TX, WA - UnitedHealthcare West Benefit…
343. united-healthcare-bip197-lGender Dysphoria (Gender Identity Disorder) Treatment (for Washington Only): WA…
344. united-healthcare-bip198-jGender Dysphoria (Gender Identity Disorder) Treatment (for Oregon Only): OR…
345. united-healthcare-bip201-iHabilitative Services: CA - UnitedHealthcare West Benefit Interpretation Policy
346. united-healthcare-bip202-iHabilitative Services: OK, OR, TX, WA - UnitedHealthcare West Benefit Interpretation…
347. Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors - Oxford Clinical…
348. Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the…
349. Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) - Oxford Clinical Policy
350. Electric Tumor Treatment Field Therapy - Oxford Clinical Policy
351. Cardiac Event Monitoring - Oxford Clinical Policy
352. Cardiovascular Disease Risk Tests - Oxford Clinical Policy
353. Transcatheter Procedures for Heart Valve Conditions - Oxford Clinical Policy
354. Cardiology Procedures for eviCore healthcare Arrangement - Oxford Clinical Policy
355. united-healthcare-cdg-001-16Ambulance Services - Commercial and Individual Exchange Medical Policy
356. united-healthcare-cdg-008-12Skilled Care and Custodial Care Services – Commercial Coverage Determination Guideline
357. united-healthcare-cdg-009-25Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements…
358. united-healthcare-cdg-016-43Preventive Care Services - Commercial and Individual Exchange Medical Policy
359. united-healthcare-cdg-017-12Private Duty Nursing Services - Commercial and Individual Exchange Medical Policy
360. united-healthcare-cdg-018-13Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs – Commercial…
361. united-healthcare-cdg-022-18Home Health, Skilled, and Custodial Care Services (for Commercial Only) - Commercial and…
362. united-healthcare-cdg-026-16Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) - Commercial…
363. united-healthcare-cdg-027-06Enteral Nutrition (Oral and Tube Feeding) - Commercial and Individual Exchange Medical…
364. united-healthcare-cdg-030-03Manual Wheelchairs – Commercial Coverage Determination Guideline
365. united-healthcare-cdg-032-04Power Mobility Devices – Commercial Coverage Determination Guideline
366. united-healthcare-cdg-034-04Wheelchair Options and Accessories – Commercial Coverage Determination Guideline
367. united-healthcare-cdg-035-04Wheelchair Seating – Commercial Coverage Determination Guideline
368. united-healthcare-cs001ne-lAblative Treatment for Spinal Pain (for Nebraska Only) – Community Plan Medical Policy
369. united-healthcare-cs001nj-mAblative Treatment for Spinal Pain (for New Jersey Only) - Community Plan Medical Policy
370. united-healthcare-cs001-oAblative Treatment for Spinal Pain - Community Plan Medical Policy
371. united-healthcare-cs002-abAbnormal Uterine Bleeding and Uterine Fibroids - Community Plan Medical Policy
372. united-healthcare-cs002nj-zAbnormal Uterine Bleeding and Uterine Fibroids (for New Jersey Only) - Community Plan…
373. united-healthcare-cs003ne-nAmbulance Services (for Nebraska Only) - Community Plan Medical Policy
374. united-healthcare-cs003nj-lAmbulance Services (for New Jersey Only) - Community Plan Medical Policy
375. united-healthcare-cs003-oAmbulance Services - Community Plan Medical Policy
376. united-healthcare-cs004-nApheresis - Community Plan Medical Policy
377. united-healthcare-cs004nj-kApheresis (for New Jersey Only) - Community Plan Medical Policy
378. united-healthcare-cs005-mAthletic Pubalgia Surgery - Community Plan Medical Policy
379. united-healthcare-cs005nj-lAthletic Pubalgia Surgery (for New Jersey Only) - Community Plan Medical Policy
380. united-healthcare-cs006ne-nArticular Cartilage Defect Repairs (for Nebraska Only) – Community Plan Medical Policy
381. united-healthcare-cs006nj-iArticular Cartilage Defect Repairs (for New Jersey Only) – Community Plan Medical Policy
382. united-healthcare-cs006-pArticular Cartilage Defect Repairs – Community Plan Medical Policy
383. united-healthcare-cs007ne-sBariatric Surgery (for Nebraska Only) - Community Plan Medical Policy
384. united-healthcare-cs007nj-lBariatric Surgery (for New Jersey Only) - Community Plan Medical Policy
385. united-healthcare-cs007-rBariatric Surgery - Community Plan Medical Policy
386. united-healthcare-cs008nj-qBrow Ptosis and Eyelid Repair (for New Jersey Only) - Community Plan Medical Policy
387. united-healthcare-cs008-uBrow Ptosis and Eyelid Repair - Community Plan Medical Policy
388. united-healthcare-cs009nj-nSpinal Fusion and Bone Healing Enhancement Products (for New Jersey Only) - Community Plan…
389. united-healthcare-cs009-qSpinal Fusion and Bone Healing Enhancement Products - Community Plan Medical Policy
390. united-healthcare-cs010nj-sBreast Imaging for Screening and Diagnosing Cancer (for New Jersey Only) - Community Plan…
391. united-healthcare-cs010-tBreast Imaging for Screening and Diagnosing Cancer - Community Plan Medical Policy
392. united-healthcare-cs011ne-sBreast Reconstruction (for Nebraska Only) - Community Plan Medical Policy
393. united-healthcare-cs011nj-qBreast Reconstruction (for New Jersey Only) - Community Plan Medical Policy
394. united-healthcare-cs011-tBreast Reconstruction - Community Plan Medical Policy
395. united-healthcare-cs012nj-rBreast Reduction Surgery (for New Jersey Only) - Community Plan Medical Policy
396. united-healthcare-cs012-yBreast Reduction Surgery - Community Plan Medical Policy
397. united-healthcare-cs014-lBronchial Thermoplasty - Community Plan Medical Policy
398. united-healthcare-cs014nj-kBronchial Thermoplasty (for New Jersey Only) - Community Plan Medical Policy
399. united-healthcare-cs015nj-lCardiovascular Disease Risk Tests (for New Jersey Only) - Community Plan Medical Policy
400. united-healthcare-cs015-pCardiovascular Disease Risk Tests - Community Plan Medical Policy
401. united-healthcare-cs016-lChelation Therapy - Community Plan Medical Policy
402. united-healthcare-cs016nj-jChelation Therapy for Non-Overload Conditions (for New Jersey Only) - Community Plan…
403. united-healthcare-cs017ne-bChromosome Microarray Testing (Non-Oncology Conditions) (for Nebraska Only) - Community…
404. united-healthcare-cs017nj-tChromosome Microarray Testing (Non-Oncology Conditions) (for New Jersey Only) - Community…
405. united-healthcare-cs017-wChromosome Microarray Testing (Non-Oncology Conditions) - Community Plan Medical Policy
406. united-healthcare-cs018ne-uMandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for…
407. united-healthcare-cs018nj-oClinical Trials (for New Jersey Only) - Community Plan Medical Policy
408. united-healthcare-cs018nj-qMandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for…
409. united-healthcare-cs018-rClinical Trials - Community Plan Medical Policy
410. united-healthcare-cs018ss-qMandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials…
411. united-healthcare-cs019nj-nCochlear Implants (for New Jersey Only) - Community Plan Medical Policy
412. united-healthcare-cs019-pCochlear Implants - Community Plan Medical Policy
413. united-healthcare-cs020nj-lCognitive Rehabilitation (for New Jersey Only) - Community Plan Medical Policy
414. united-healthcare-cs020-pCognitive Rehabilitation - Community Plan Medical Policy
415. united-healthcare-cs021-mCollagen Crosslinks and Biochemical Markers of Bone Turnover - Community Plan Medical…
416. united-healthcare-cs021nj-iCollagen Crosslinks and Biochemical Markers of Bone Turnover (for New Jersey Only)…
417. united-healthcare-cs022-kComputed Tomographic Colonography - Community Plan Medical Policy
418. united-healthcare-cs022nj-hComputed Tomographic Colonography (for New Jersey Only) - Community Plan Medical Policy
419. united-healthcare-cs023nj-lComputerized Dynamic Posturography (for New Jersey Only) - Community Plan Medical Policy
420. united-healthcare-cs023-oComputerized Dynamic Posturography - Community Plan Medical Policy
421. united-healthcare-cs024ne-wContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Nebraska…
422. united-healthcare-cs024nj-xContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for New Jersey…
423. united-healthcare-cs024ss-aaContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes - Community Plan…
424. united-healthcare-cs025-kCore Decompression for Avascular Necrosis - Community Plan Medical Policy
425. united-healthcare-cs025nj-jCore Decompression for Avascular Necrosis (for New Jersey Only) - Community Plan Medical…
426. united-healthcare-cs026-nCorneal Hysteresis and Intraocular Pressure Measurement - Community Plan Medical Policy
427. united-healthcare-cs026nj-mCorneal Hysteresis and Intraocular Pressure Measurement (for New Jersey Only) - Community…
428. united-healthcare-cs027ne-pCosmetic and Reconstructive Procedures (for Nebraska Only) - Community Plan Medical Policy
429. united-healthcare-cs027nj-rCosmetic and Reconstructive Procedures (for New Jersey Only) - Community Plan Medical…
430. united-healthcare-cs027-yCosmetic and Reconstructive Procedures - Community Plan Medical Policy
431. united-healthcare-cs028-kSkilled Care and Custodial Care Services – Community Plan Coverage Determination Guideline
432. united-healthcare-cs028ne-kSkilled Care and Custodial Care Services (for Nebraska Only) - Community Plan Coverage…
433. united-healthcare-cs028nj-jSkilled Care and Custodial Care Services (for New Jersey Only) – Community Plan Coverage…
434. united-healthcare-cs029nj-pCytological Examination of Breast Fluids for Cancer Screening or Diagnosis (for New Jersey…
435. united-healthcare-cs029-qCytological Examination of Breast Fluids for Cancer Screening or Diagnosis - Community…
436. united-healthcare-cs030nj-iDeep Brain and Cortical Stimulation (for New Jersey Only) - Community Plan Medical Policy
437. united-healthcare-cs030-pDeep Brain and Cortical Stimulation - Community Plan Medical Policy
438. united-healthcare-cs031nj-nDiscogenic Pain Treatment (for New Jersey Only) - Community Plan Medical Policy
439. united-healthcare-cs031-pDiscogenic Pain Treatment - Community Plan Medical Policy
440. united-healthcare-cs032ne-sDurable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for…
441. united-healthcare-cs032nj-rDurable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for New…
442. united-healthcare-cs032-wDurable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements…
443. united-healthcare-cs033nj-nSurgery of the Elbow (for New Jersey Only) - Community Plan Medical Policy
444. united-healthcare-cs033-qSurgery of the Elbow - Community Plan Medical Policy
445. united-healthcare-cs034-nElectrical Bioimpedance for Cardiac Output Measurement – Community Plan Medical Policy
446. united-healthcare-cs035-kElectrical Stimulation and Electromagnetic Therapy for Wounds - Community Plan Medical…
447. united-healthcare-cs035-mElectromagnetic Therapy for Wounds - Community Plan Medical Policy
448. united-healthcare-cs035nj-gElectrical Stimulation and Electromagnetic Therapy for Wounds (for New Jersey Only)…
449. united-healthcare-cs035nj-iElectromagnetic Therapy for Wounds (for New Jersey Only) - Community Plan Medical Policy
450. united-healthcare-cs036ne-pElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for Nebraska…
451. united-healthcare-cs036nj-nElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for New Jersey…
452. united-healthcare-cs036-sElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Community…
453. united-healthcare-cs037ne-oElectrical and Ultrasound Bone Growth Stimulators (for Nebraska Only) - Community Plan…
454. united-healthcare-cs037nj-rElectrical and Ultrasound Bone Growth Stimulators (for New Jersey Only) - Community Plan…
455. united-healthcare-cs037-pElectrical and Ultrasound Bone Growth Stimulators - Community Plan Medical Policy
456. united-healthcare-cs039ne-rEpidural Steroid Injections for Spinal Pain (for Nebraska Only) – Community Plan Medical…
457. united-healthcare-cs039nj-pEpidural Steroid Injections for Spinal Pain (for New Jersey Only) - Community Plan Medical…
458. united-healthcare-cs039-vEpidural Steroid Injections for Spinal Pain - Community Plan Medical Policy
459. united-healthcare-cs040-lEpiduroscopy, Epidural Lysis of Adhesions, and Discography - Community Plan Medical Policy
460. united-healthcare-cs040nj-hEpiduroscopy, Epidural Lysis of Adhesions and Discography (for New Jersey Only)…
461. united-healthcare-cs041nj-oExtracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue…
462. united-healthcare-cs041-rExtracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue…
463. united-healthcare-cs042-nFecal Calprotectin Testing - Community Plan Medical Policy
464. united-healthcare-cs042nj-jFecal Calprotectin Testing (for New Jersey Only) - Community Plan Medical Policy
465. united-healthcare-cs046-nGastrointestinal Motility Disorders, Diagnosis and Treatment - Community Plan Medical…
466. united-healthcare-cs046nj-lGastrointestinal Motility Disorders, Diagnosis and Treatment (for New Jersey Only)…
467. united-healthcare-cs048ne-bGenetic Testing for Cardiac Disease (for Nebraska Only) - Community Plan Medical Policy
468. united-healthcare-cs048nj-lGenetic Testing for Cardiac Disease (for New Jersey Only) - Community Plan Medical Policy
469. united-healthcare-cs048-oGenetic Testing for Cardiac Disease - Community Plan Medical Policy
470. united-healthcare-cs049ne-bGenetic Testing for Hereditary Cancer (for Nebraska Only) - Community Plan Medical Policy
471. united-healthcare-cs049nj-qGenetic Testing for Hereditary Cancer (for New Jersey Only) - Community Plan Medical…
472. united-healthcare-cs049-tGenetic Testing for Hereditary Cancer - Community Plan Medical Policy
473. united-healthcare-cs050nj-pGlaucoma Surgical Treatments (for New Jersey Only) - Community Plan Medical Policy
474. united-healthcare-cs050-sGlaucoma Surgical Treatments - Community Plan Medical Policy
475. united-healthcare-cs051fl-nGynecomastia Surgery (for Florida Only) - Community Plan Medical Policy
476. united-healthcare-cs051-nGynecomastia Surgery - Community Plan Medical Policy
477. united-healthcare-cs051nj-jGynecomastia Surgery (for New Jersey Only) - Community Plan Medical Policy
478. united-healthcare-cs052nj-nHearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable (for New…
479. united-healthcare-cs052-qHearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable…
480. united-healthcare-cs053ne-rHepatitis Screening (for Nebraska Only) - Community Plan Medical Policy
481. united-healthcare-cs053nj-rHepatitis Screening (for New Jersey Only) - Community Plan Medical Policy
482. united-healthcare-cs053-sHepatitis Screening - Community Plan Medical Policy
483. united-healthcare-cs054nj-oAirway Clearance Devices (for New Jersey Only) - Community Plan Medical Policy
484. united-healthcare-cs054-rAirway Clearance Devices - Community Plan Medical Policy
485. united-healthcare-cs056nj-oSurgery of the Hip (for New Jersey Only) - Community Plan Medical Policy
486. united-healthcare-cs056-tSurgery of the Hip - Community Plan Medical Policy
487. united-healthcare-cs057-lHome Hemodialysis - Community Plan Medical Policy
488. united-healthcare-cs057nj-iHome Hemodialysis (for New Jersey Only) - Community Plan Medical Policy
489. united-healthcare-cs058-mHome Traction Therapy - Community Plan Medical Policy
490. united-healthcare-cs058ne-mHome Traction Therapy (for Nebraska Only) - Community Plan Medical Policy
491. united-healthcare-cs058nj-mHome Traction Therapy (for New Jersey Only) - Community Plan Medical Policy
492. united-healthcare-cs060-lImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors - Community Plan…
493. united-healthcare-cs060-nTransarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the…
494. united-healthcare-cs060nj-jImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors (for New Jersey…
495. united-healthcare-cs060nj-lTransarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the…
496. united-healthcare-cs061ne-vImplanted Electrical Stimulator for Spinal Cord (for Nebraska Only) – Community Plan…
497. united-healthcare-cs061nj-tImplanted Electrical Stimulator for Spinal Cord (for New Jersey Only) - Community Plan…
498. united-healthcare-cs061-wImplanted Electrical Stimulator for the Spinal Cord - Community Plan Medical Policy
499. united-healthcare-cs062-nIntrauterine Fetal Surgery - Community Plan Medical Policy
500. united-healthcare-cs062ne-kIntrauterine Fetal Surgery (for Nebraska Only) - Community Plan Medical Policy
501. united-healthcare-cs062nj-lIntrauterine Fetal Surgery (for New Jersey Only) - Community Plan Medical Policy
502. united-healthcare-cs064ne-oIntensity-Modulated Radiation Therapy (for Nebraska Only) – Community Plan Medical Policy
503. united-healthcare-cs064nj-mIntensity-Modulated Radiation Therapy (for New Jersey Only) - Community Plan Medical…
504. united-healthcare-cs064-pIntensity-Modulated Radiation Therapy - Community Plan Medical Policy
505. united-healthcare-cs068nj-sSurgery of the Knee (for New Jersey Only) - Community Plan Medical Policy
506. united-healthcare-cs068-vSurgery of the Knee - Community Plan Medical Policy
507. united-healthcare-cs069nj-nLight and Laser Therapy (for New Jersey Only) - Community Plan Medical Policy
508. united-healthcare-cs069-pLight and Laser Therapy - Community Plan Medical Policy
509. united-healthcare-cs070-lLithotripsy for Salivary Stones - Community Plan Medical Policy
510. united-healthcare-cs070nj-jLithotripsy for Salivary Stones (for New Jersey Only) - Community Plan Medical Policy
511. united-healthcare-cs072-nMacular Degeneration Treatment Procedures - Community Plan Medical Policy
512. united-healthcare-cs072nj-kMacular Degeneration Treatment Procedures (for New Jersey Only) - Community Plan Medical…
513. united-healthcare-cs075nj-lManipulation Under Anesthesia (for New Jersey Only) - Community Plan Medical Policy
514. united-healthcare-cs075-pManipulation Under Anesthesia - Community Plan Medical Policy
515. united-healthcare-cs076-lManipulative Therapy - Community Plan Medical Policy
516. united-healthcare-cs076ne-kManipulative Therapy (for Nebraska Only) - Community Plan Medical Policy
517. united-healthcare-cs076nj-kManipulative Therapy (for New Jersey Only) - Community Plan Medical Policy
518. united-healthcare-cs077-lMechanical Stretching Devices - Community Plan Medical Policy
519. united-healthcare-cs077nj-jMechanical Stretching Devices (for New Jersey Only) - Community Plan Medical Policy
520. united-healthcare-cs078-mMeniscus Implant and Allograft – Community Plan Medical Policy
521. united-healthcare-cs078nj-lMeniscus Implant and Allograft (for New Jersey Only) – Community Plan Medical Policy
522. united-healthcare-cs079ne-nMinimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia…
523. united-healthcare-cs079nj-lMinimally Invasive Procedures for Gastric and Esophageal Diseases (for New Jersey Only)…
524. united-healthcare-cs079-pMinimally Invasive Procedures for Gastric and Esophageal Diseases - Community Plan Medical…
525. united-healthcare-cs080-mMotorized Spinal Traction - Community Plan Medical Policy
526. united-healthcare-cs080nj-kMotorized Spinal Traction (for New Jersey Only) - Community Plan Medical Policy
527. united-healthcare-cs081-kNerve Graft to Restore Erectile Function During Radical Prostatectomy - Community Plan…
528. united-healthcare-cs081nj-iNerve Graft to Restore Erectile Function During Radical Prostatectomy (for New Jersey…
529. united-healthcare-cs082nj-oNeurophysiologic Testing and Monitoring (for New Jersey Only) - Community Plan Medical…
530. united-healthcare-cs082-qNeurophysiologic Testing and Monitoring - Community Plan Medical Policy
531. united-healthcare-cs083ne-pNeuropsychological Testing Under the Medical Benefit (for Nebraska Only) - Community Plan…
532. united-healthcare-cs083nj-mNeuropsychological Testing Under the Medical Benefit (for New Jersey Only) - Community…
533. united-healthcare-cs083-pNeuropsychological Testing Under the Medical Benefit - Community Plan Medical Policy
534. united-healthcare-cs085ne-bCell-Free Fetal DNA Testing (for Nebraska Only) - Community Plan Medical Policy
535. united-healthcare-cs085nj-vCell-Free Fetal DNA Testing (for New Jersey Only) - Community Plan Medical Policy
536. united-healthcare-cs085-yCell-Free Fetal DNA Testing - Community Plan Medical Policy
537. united-healthcare-cs086ne-tOccipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for…
538. united-healthcare-cs086nj-tOccipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for…
539. united-healthcare-cs086-wOccipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)…
540. united-healthcare-cs087-asOmnibus Codes - Community Plan Medical Policy
541. united-healthcare-cs087ne-ajOmnibus Codes (for Nebraska Only) - Community Plan Medical Policy
542. united-healthcare-cs087nj-amOmnibus Codes (for New Jersey Only) - Community Plan Medical Policy
543. united-healthcare-cs088ne-qOrthognathic (Jaw) Surgery (for Nebraska Only) - Community Plan Medical Policy
544. united-healthcare-cs088nj-rOrthognathic (Jaw) Surgery (for New Jersey Only) - Community Plan Medical Policy
545. united-healthcare-cs088-sOrthognathic (Jaw) Surgery - Community Plan Medical Policy
546. united-healthcare-cs092nj-sCardiac Event Monitoring (for New Jersey Only) - Community Plan Medical Policy
547. united-healthcare-cs092-rCardiac Event Monitoring - Community Plan Medical Policy
548. united-healthcare-cs093ne-rPanniculectomy and Body Contouring Procedures (for Nebraska Only) - Community Plan Medical…
549. united-healthcare-cs093nj-sPanniculectomy and Body Contouring Procedures (for New Jersey Only) - Community Plan…
550. united-healthcare-cs093-uPanniculectomy and Body Contouring Procedures - Community Plan Medical Policy
551. united-healthcare-cs094nj-nPectus Deformity Repair (for New Jersey Only) - Community Plan Medical Policy
552. united-healthcare-cs094-rPectus Deformity Repair - Community Plan Medical Policy
553. united-healthcare-cs095nj-iPlagiocephaly and Craniosynostosis Treatment (for New Jersey Only) - Community Plan…
554. united-healthcare-cs095-pPlagiocephaly and Craniosynostosis Treatment - Community Plan Medical Policy
555. united-healthcare-cs097ne-oPneumatic Compression Devices (for Nebraska Only) - Community Plan Medical Policy
556. united-healthcare-cs097nj-nPneumatic Compression Devices (for New Jersey Only) - Community Plan Medical Policy
557. united-healthcare-cs097-oPneumatic Compression Devices - Community Plan Medical Policy
558. united-healthcare-cs098-aaSleep Studies - Community Plan Medical Policy
559. united-healthcare-cs098nj-wAttended Polysomnography for Evaluation of Sleep Disorders (for New Jersey Only)…
560. united-healthcare-cs098nj-ySleep Studies (for New Jersey Only) - Community Plan Medical Policy
561. united-healthcare-cs098-zAttended Polysomnography for Evaluation of Sleep Disorders – Community Plan Medical Policy
562. united-healthcare-cs102fl-ePrivate Duty Nursing Services (for Florida Only) - Community Plan Medical Policy
563. united-healthcare-cs102ne-lPrivate Duty Nursing Services (for Nebraska Only) - Community Plan Medical Policy
564. united-healthcare-cs102nj-dPrivate Duty Nursing Services (for New Jersey Only) - Community Plan Medical Policy
565. united-healthcare-cs102-qPrivate Duty Nursing Services - Community Plan Medical Policy
566. united-healthcare-cs103nj-pProlotherapy and Platelet Rich Plasma Therapies (for New Jersey Only) - Community Plan…
567. united-healthcare-cs103-rProlotherapy and Platelet Rich Plasma Therapies - Community Plan Medical Policy
568. united-healthcare-cs104ne-lProsthetic Devices, Specialized, Microprocessor or Myoelectric Limbs (for Nebraska Only)…
569. united-healthcare-cs104nj-mProsthetic Devices, Specialized, Microprocessor or Myoelectric Limbs (for New Jersey Only)…
570. united-healthcare-cs104-oProsthetic Devices, Specialized, Microprocessor or Myoelectric Limbs – Community Plan…
571. united-healthcare-cs105ne-oProton Beam Radiation Therapy (for Nebraska Only) – Community Plan Medical Policy
572. united-healthcare-cs105nj-mProton Beam Radiation Therapy (for New Jersey Only) - Community Plan Medical Policy
573. united-healthcare-cs105-pProton Beam Radiation Therapy - Community Plan Medical Policy
574. united-healthcare-cs107-aaRhinoplasty and Other Nasal Procedures - Community Plan Medical Policy
575. united-healthcare-cs107ne-tRhinoplasty and Other Nasal Procedures (for Nebraska Only) - Community Plan Medical Policy
576. united-healthcare-cs107nj-vRhinoplasty and Other Nasal Procedures (for New Jersey Only) - Community Plan Medical…
577. united-healthcare-cs108-kSensory Integration Therapy and Auditory Integration Training - Community Plan Medical…
578. united-healthcare-cs108nj-iSensory Integration Therapy and Auditory Integration Training (for New Jersey Only)…
579. united-healthcare-cs109nj-pSurgery of the Shoulder (for New Jersey Only) - Community Plan Medical Policy
580. united-healthcare-cs109-uSurgery of the Shoulder - Community Plan Medical Policy
581. united-healthcare-cs112ne-tSpeech Language Pathology Services (for Nebraska Only) – Community Plan Coverage…
582. united-healthcare-cs112nj-sSpeech Language Pathology Services (for New Jersey Only) - Community Plan Coverage…
583. united-healthcare-cs112-uSpeech Language Pathology Services – Community Plan Coverage Determination Guideline
584. united-healthcare-cs113-nDiagnostic Spinal Ultrasonography - Community Plan Medical Policy
585. united-healthcare-cs113nj-mDiagnostic Spinal Ultrasonography (for New Jersey Only) - Community Plan Medical Policy
586. united-healthcare-cs115-acSurgical Treatment for Spine Pain – Community Plan Medical Policy
587. united-healthcare-cs115ne-ySurgical Treatment for Spine Pain (for Nebraska Only) – Community Plan Medical Policy
588. united-healthcare-cs115nj-zSurgical Treatment for Spine Pain (for New Jersey Only) – Community Plan Medical Policy
589. united-healthcare-cs116-adObstructive and Central Sleep Apnea Treatment - Community Plan Medical Policy
590. united-healthcare-cs116ne-aaObstructive and Central Sleep Apnea Treatment (for Nebraska Only) - Community Plan Medical…
591. united-healthcare-cs116nj-abObstructive and Central Sleep Apnea Treatment (for New Jersey Only) - Community Plan…
592. united-healthcare-cs117nj-rSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for New…
593. united-healthcare-cs117-xSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins - Community…
594. united-healthcare-cs120-mThermography – Community Plan Medical Policy
595. united-healthcare-cs120nj-kThermography (for New Jersey Only) – Community Plan Medical Policy
596. united-healthcare-cs121nj-mTotal Artificial Disc Replacement for the Spine (for New Jersey Only) - Community Plan…
597. united-healthcare-cs121-uTotal Artificial Disc Replacement for the Spine - Community Plan Medical Policy
598. united-healthcare-cs122ne-qVentricular Assist Devices (for Nebraska Only) - Community Plan Medical Policy
599. united-healthcare-cs122nj-lTotal Artificial Heart and Ventricular Assist Devices (for New Jersey Only) - Community…
600. united-healthcare-cs122-oTotal Artificial Heart and Ventricular Assist Devices - Community Plan Medical Policy
601. united-healthcare-cs123ne-qTranscatheter Heart Valve Procedures (for Nebraska Only) - Community Plan Medical Policy
602. united-healthcare-cs123nj-nTranscatheter Heart Valve Procedures (for New Jersey Only) - Community Plan Medical Policy
603. united-healthcare-cs123-sTranscatheter Procedures for Heart Valve Conditions - Community Plan Medical Policy
604. united-healthcare-cs124-lTranscranial Magnetic Stimulation - Community Plan Medical Policy
605. united-healthcare-cs124nj-hTranscranial Magnetic Stimulation (for New Jersey Only) - Community Plan Medical Policy
606. united-healthcare-cs127-mUmbilical Cord Blood Harvesting and Storage for Future Use - Community Plan Medical Policy
607. united-healthcare-cs127nj-kUmbilical Cord Blood Harvesting and Storage for Future Use (for New Jersey Only)…
608. united-healthcare-cs128-kUnicondylar Spacer Devices for Treatment of Pain or Disability - Community Plan Medical…
609. united-healthcare-cs128nj-iUnicondylar Spacer Devices for Treatment of Pain or Disability (for New Jersey Only)…
610. united-healthcare-cs129nj-lVagus and External Trigeminal Nerve Stimulation (for New Jersey Only) - Community Plan…
611. united-healthcare-cs129-qVagus and External Trigeminal Nerve Stimulation - Community Plan Medical Policy
612. united-healthcare-cs130-kVirtual Upper Gastrointestinal Endoscopy - Community Plan Medical Policy
613. united-healthcare-cs130nj-jVirtual Upper Gastrointestinal Endoscopy (for New Jersey Only) - Community Plan Medical…
614. united-healthcare-cs131-lVisual Information Processing Evaluation and Orthoptic and Vision Therapy - Community Plan…
615. united-healthcare-cs132-lNoncontact Warming Therapy, Ultrasound Therapy, and Fluorescence Imaging for Wounds…
616. united-healthcare-cs132ne-kNoncontact Warming Therapy, Ultrasound Therapy and Fluorescence Imaging for Wounds (for…
617. united-healthcare-cs132nj-kNoncontact Warming Therapy, Ultrasound Therapy, and Fluorescence Imaging for Wounds (for…
618. united-healthcare-cs134-lTranspupillary Thermotherapy - Community Plan Medical Policy
619. united-healthcare-cs134nj-jTranspupillary Thermotherapy (for New Jersey Only) - Community Plan Medical Policy
620. united-healthcare-cs136-lOral and Enteral Nutrition – Community Plan Medical Policy
621. united-healthcare-cs136ne-iOral and Enteral Nutrition (for Nebraska Only) – Community Plan Coverage Determination…
622. united-healthcare-cs136ne-lEnteral Nutrition (Oral and Tube Feeding) (for Nebraska Only) - Community Plan Medical…
623. united-healthcare-cs136nj-jOral and Enteral Nutrition (for New Jersey Only) – Community Plan Coverage Determination…
624. united-healthcare-cs136nj-mEnteral Nutrition (Oral and Tube Feeding) (for New Jersey Only) - Community Plan Medical…
625. united-healthcare-cs136-oEnteral Nutrition (Oral and Tube Feeding) - Community Plan Medical Policy
626. united-healthcare-cs137ne-pHome Health, Skilled, and Custodial Care Services (for Nebraska Only) - Community Plan…
627. united-healthcare-cs137nj-qHome Health, Skilled, and Custodial Care Services (for New Jersey Only) - Community Plan…
628. united-healthcare-cs137-qHome Health, Skilled, and Custodial Care Services - Community Plan Medical Policy
629. united-healthcare-cs138nj-jBalloon Sinus Ostial Dilation (for New Jersey Only) - Community Plan Medical Policy
630. united-healthcare-cs138nj-mSinus Surgeries and Interventions (for New Jersey Only) - Community Plan Medical Policy
631. united-healthcare-cs138-oBalloon Sinus Ostial Dilation - Community Plan Medical Policy
632. united-healthcare-cs138-qSinus Surgeries and Interventions - Community Plan Medical Policy
633. united-healthcare-cs139-nEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome - Community…
634. united-healthcare-cs139nj-kEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for New Jersey…
635. united-healthcare-cs141-kIntraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) - Community Plan Medical…
636. united-healthcare-cs141nj-jIntraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (for New Jersey Only)…
637. united-healthcare-cs143nj-lOutpatient Surgical Procedures - Site of Service (for New Jersey Only) - Community Plan…
638. united-healthcare-cs143-pOutpatient Surgical Procedures - Site of Service - Community Plan Medical Policy
639. united-healthcare-cs144nj-iFunctional Endoscopic Sinus Surgery (FESS) (for New Jersey Only) - Community Plan Medical…
640. united-healthcare-cs144-pFunctional Endoscopic Sinus Surgery (FESS) - Community Plan Medical Policy
641. united-healthcare-cs145-lGender Dysphoria Treatment - Community Plan Medical Policy
642. united-healthcare-cs145nj-hGender Dysphoria Treatment (for New Jersey Only) - Community Plan Medical Policy
643. united-healthcare-cs146-iElectric Tumor Treatment Field Therapy - Community Plan Medical Policy
644. united-healthcare-cs146nj-fElectric Tumor Treatment Field Therapy (for New Jersey Only) - Community Plan Medical…
645. united-healthcare-cs148-kLaser Interstitial Thermal Therapy – Community Plan Medical Policy
646. united-healthcare-cs148nj-hLaser Interstitial Thermal Therapy (for New Jersey Only) – Community Plan Medical Policy
647. united-healthcare-cs149-nPharmacogenetic Panel Testing - Community Plan Medical Policy
648. united-healthcare-cs149ne-cPharmacogenetic Panel Testing (for Nebraska Only) - Community Plan Medical Policy
649. united-healthcare-cs149nj-kPharmacogenetic Panel Testing (for New Jersey Only) - Community Plan Medical Policy
650. united-healthcare-cs150-mWhole Exome and Whole Genome Sequencing (Non-Oncology Conditions) - Community Plan Medical…
651. united-healthcare-cs150ne-aWhole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Nebraska Only)…
652. united-healthcare-cs150nj-kWhole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for New Jersey Only)…
653. united-healthcare-cs151-hCarrier Testing Panels for Genetic Diseases - Community Plan Medical Policy
654. united-healthcare-cs151ne-bCarrier Testing Panels for Genetic Diseases (for Nebraska Only) - Community Plan Medical…
655. united-healthcare-cs151nj-gCarrier Testing Panels for Genetic Diseases (for New Jersey Only) - Community Plan Medical…
656. united-healthcare-cs152ne-bMolecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment…
657. united-healthcare-cs152nj-rMolecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment…
658. united-healthcare-cs152-sMolecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment…
659. united-healthcare-cs153-nSkin and Soft Tissue Substitutes - Community Plan Medical Policy
660. united-healthcare-cs153ne-kSkin and Soft Tissue Substitutes (for Nebraska Only) - Community Plan Medical Policy
661. united-healthcare-cs153nj-jSkin and Soft Tissue Substitutes (for New Jersey Only) - Community Plan Medical Policy
662. united-healthcare-cs155-lProvider Administered Drugs - Site of Care - Community Plan Medical Benefit Drug Policy
663. united-healthcare-cs155ne-jProvider Administered Drugs – Site of Care (for Nebraska Only) – Community Plan…
664. united-healthcare-cs155nj-iProvider Administered Drugs – Site of Care (for New Jersey Only) – Community Plan…
665. united-healthcare-cs157-hNegative Pressure Wound Therapy - Community Plan Medical Policy
666. united-healthcare-cs157nj-dNegative Pressure Wound Therapy (for New Jersey Only) - Community Plan Medical Policy
667. united-healthcare-cs158-lVideo Electroencephalographic (vEEG) Monitoring and Recording - Community Plan Medical…
668. united-healthcare-cs158ne-iVideo Electroencephalographic (vEEG) Monitoring and Recording (for Nebraska Only)…
669. united-healthcare-cs158nj-hVideo Electroencephalographic (vEEG) Monitoring and Recording (for New Jersey Only)…
670. united-healthcare-cs159-hPediatric Gait Trainers, Standing Systems, and Walkers – Community Plan Coverage…
671. united-healthcare-cs159-kPediatric Gait Trainers and Standing Systems - Community Plan Medical Policy
672. united-healthcare-cs159ne-ePediatric Gait Trainers, Standing Systems, and Walkers (for Nebraska Only) – Community…
673. united-healthcare-cs159ne-gPediatric Gait Trainers and Standing Systems (for Nebraska Only) - Community Plan Medical…
674. united-healthcare-cs159nj-hPediatric Gait Trainers, Standing Systems, and Walkers (for New Jersey Only) – Community…
675. united-healthcare-cs159nj-kPediatric Gait Trainers and Standing Systems (for New Jersey Only) - Community Plan…
676. united-healthcare-cs160-gPreimplantation Genetic Testing and Related Services - Community Plan Medical Policy
677. united-healthcare-cs160ne-aPreimplantation Genetic Testing and Related Services (for Nebraska Only) - Community Plan…
678. united-healthcare-cs160nj-dPreimplantation Genetic Testing and Related Services (for New Jersey Only) - Community…
679. united-healthcare-cs161fl-iOutpatient Speech, Occupational and Physical Therapy – Site of Service (for Florida Only)…
680. united-healthcare-cs161fl-jHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) - Site of…
681. united-healthcare-cs162fl-iOutpatient Speech, Occupational and Physical Therapy Services (for Florida Only)…
682. united-healthcare-cs164fl-kHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida…
683. united-healthcare-cs164-hOutpatient Physical and Occupational Therapy – Community Plan Coverage Determination…
684. united-healthcare-cs164-jHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) - Community…
685. united-healthcare-cs164ne-fOutpatient Physical and Occupational Therapy (for Nebraska Only) – Community Plan Coverage…
686. united-healthcare-cs164ne-hHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Nebraska…
687. united-healthcare-cs164nj-dOutpatient Physical and Occupational Therapy (for New Jersey Only) - Community Plan…
688. united-healthcare-cs164nj-fHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New…
689. united-healthcare-cs165-eGenetic Testing for Neuromuscular Disorders - Community Plan Medical Policy
690. united-healthcare-cs165ne-bGenetic Testing for Neuromuscular Disorders (for Nebraska Only) - Community Plan Medical…
691. united-healthcare-cs165nj-cGenetic Testing for Neuromuscular Disorders (for New Jersey Only) - Community Plan Medical…
692. united-healthcare-cs166-jLower Extremity Endovascular Procedures - Community Plan Medical Policy
693. united-healthcare-cs166ne-jLower Extremity Endovascular Procedures (for Nebraska Only) – Community Plan Medical…
694. united-healthcare-cs166nj-hLower Extremity Endovascular Procedures (for New Jersey Only) - Community Plan Medical…
695. united-healthcare-cs167-fComputer-Assisted Surgical Navigation for Musculoskeletal Procedures - Community Plan…
696. united-healthcare-cs167nj-cComputer-Assisted Surgical Navigation for Musculoskeletal Procedures (for New Jersey Only)…
697. united-healthcare-cs168fl-dCertified Nursing Assistant (CNA) or Home Health Aide for Adults Age 21 and Older (for…
698. united-healthcare-cs169-jGastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea…
699. united-healthcare-cs169ne-aGastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea…
700. united-healthcare-cs169nj-cGastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea…
701. united-healthcare-cs170-fVertebral Body Tethering for Scoliosis - Community Plan Medical Policy
702. united-healthcare-cs170nj-cVertebral Body Tethering for Scoliosis (for New Jersey Only) - Community Plan Medical…
703. united-healthcare-cs172-lGenitourinary Pathogen Nucleic Acid Detection Panel Testing – Community Plan Medical…
704. united-healthcare-cs172nj-dGenitourinary Pathogen Nucleic Acid Detection Panel Testing (for New Jersey Only)…
705. united-healthcare-cs173-gInhaled Nitric Oxide Therapy - Community Plan Medical Policy
706. united-healthcare-cs176-dAutologous Cellular Therapy - Community Plan Medical Policy
707. united-healthcare-cs176nj-aAutologous Cellular Therapy (for New Jersey Only) - Community Plan Medical Policy
708. united-healthcare-cs178-dFacet Joint and Medial Branch Block Injections for Spinal Pain - Community Plan Medical…
709. united-healthcare-cs178ne-bFacet Joint and Medial Branch Block Injections for Spinal Pain (for Nebraska Only)…
710. united-healthcare-cs178nj-bFacet Joint and Medial Branch Block Injections for Spinal Pain (for New Jersey Only)…
711. united-healthcare-cs179-eRadiation Therapy: Fractionation, Image-Guidance, and Special Services - Community Plan…
712. united-healthcare-cs179nj-bRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Jersey…
713. united-healthcare-cs180-fStereotactic Body Radiation Therapy and Stereotactic Radiosurgery - Community Plan Medical…
714. united-healthcare-cs180nj-bStereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for New Jersey Only)…
715. united-healthcare-cs181-eBeds and Mattresses - Community Plan Medical Policy
716. united-healthcare-cs181ne-eBeds and Mattresses (for Nebraska Only) - Community Plan Medical Policy
717. united-healthcare-cs181nj-dBeds and Mattresses (for New Jersey Only) - Community Plan Medical Policy
718. united-healthcare-cs182-fElective Inpatient Services - Community Plan Medical Policy
719. united-healthcare-cs182nj-bElective Inpatient Services (for New Jersey Only) - Community Plan Medical Policy
720. united-healthcare-cs184-cManual Wheelchairs – Community Plan Coverage Determination Guideline
721. united-healthcare-cs184-eMobility Devices, Options, and Accessories - Community Plan Medical Policy
722. united-healthcare-cs184ne-cManual Wheelchairs (for Nebraska Only) – Community Plan Coverage Determination Guideline
723. united-healthcare-cs184ne-fMobility Devices, Options, and Accessories (for Nebraska Only) - Community Plan Medical…
724. united-healthcare-cs184nj-bMobility Devices, Options, and Accessories (for New Jersey Only) - Community Plan Medical…
725. united-healthcare-cs185-dPatient Lifts - Community Plan Medical Policy
726. united-healthcare-cs185ne-dPatient Lifts (for Nebraska Only) - Community Plan Medical Policy
727. united-healthcare-cs185nj-aPatient Lifts (for New Jersey Only) - Community Plan Medical Policy
728. united-healthcare-cs187-dPower Mobility Devices – Community Plan Coverage Determination Guideline
729. united-healthcare-cs187ne-cPower Mobility Devices (for Nebraska Only) – Community Plan Coverage Determination…
730. united-healthcare-cs189-dSpeech Generating Devices - Community Plan Medical Policy
731. united-healthcare-cs189ne-cSpeech Generating Devices (for Nebraska Only) - Community Plan Medical Policy
732. united-healthcare-cs189nj-bSpeech Generating Devices (for New Jersey Only) - Community Plan Medical Policy
733. united-healthcare-cs191-bTranscutaneous Electrical Nerve/Joint Stimulators – Community Plan Coverage Determination…
734. united-healthcare-cs191ne-bTranscutaneous Electrical Nerve/Joint Stimulators (for Nebraska Only) – Community Plan…
735. united-healthcare-cs192-dWheelchair Options and Accessories – Community Plan Coverage Determination Guideline
736. united-healthcare-cs192ne-cWheelchair Options and Accessories (for Nebraska Only) – Community Plan Coverage…
737. united-healthcare-cs193-dWheelchair Seating – Community Plan Coverage Determination Guideline
738. united-healthcare-cs193ne-cWheelchair Seating (for Nebraska Only) – Community Plan Coverage Determination Guideline
739. united-healthcare-cs195-fTreatment of Temporomandibular Joint Disorders - Community Plan Medical Policy
740. united-healthcare-cs195ne-hTreatment of Temporomandibular Joint Disorders (for Nebraska Only) - Community Plan…
741. united-healthcare-cs195nj-cTreatment of Temporomandibular Joint Disorders (for New Jersey Only) - Community Plan…
742. united-healthcare-cs196-eHysterectomy - Community Plan Medical Policy
743. united-healthcare-cs196ne-eHysterectomy (for Nebraska Only) - Community Plan Medical Policy
744. united-healthcare-cs196nj-cHysterectomy (for New Jersey Only) - Community Plan Medical Policy
745. united-healthcare-cs197-fCatheter Ablation for Atrial Fibrillation - Community Plan Medical Policy
746. united-healthcare-cs197nj-eCatheter Ablation for Atrial Fibrillation (for New Jersey Only) - Community Plan Medical…
747. united-healthcare-cs198-fChemotherapy Observation or Inpatient Hospitalization - Community Plan Medical Policy
748. united-healthcare-cs198nj-eChemotherapy Observation or Inpatient Hospitalization (for New Jersey Only) - Community…
749. Infliximab - Community Plan Medical Benefit Drug Policy
750. Synagis® (Palivizumab) - Community Plan Medical Benefit Drug Policy
751. Intracanalicular and Intravitreal Corticosteroid Implants - Community Plan Medical Benefit…
752. Vyvgart® (Efgartigimod Alfa-Fcab) – Community Plan Medical Benefit Drug Policy
753. Korsuva® (Difelikefalin) - Community Plan Medical Benefit Drug Policy
754. Botulinum Toxins A and B - Community Plan Medical Benefit Drug Policy
755. Lemtrada® (Alemtuzumab) - Community Plan Medical Benefit Drug Policy
756. Tysabri® (Natalizumab) - Community Plan Medical Benefit Drug Policy
757. Xolair® (Omalizumab) - Community Plan Medical Benefit Drug Policy
758. Repository Corticotropin Injections - Community Plan Medical Benefit Drug Policy
759. Gonadotropin Releasing Hormone Analogs - Community Plan Medical Benefit Drug Policy
760. Orencia® (Abatacept) Injection for Intravenous Infusion - Community Plan Medical Benefit…
761. 17-Alpha-Hydroxyprogesterone Caproate (Makena® and 17P) - Community Plan Medical Benefit…
762. Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors - Community Plan…
763. Actemra® (Tocilizumab) Injection for Intravenous Infusion - Community Plan Medical Benefit…
764. Hereditary Angioedema (HAE), Treatment and Prophylaxis - Community Plan Medical Benefit…
765. Benlysta® (Belimumab) - Community Plan Medical Benefit Drug Policy
766. Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease - Community Plan Medical…
767. Complement Inhibitors - Community Plan Medical Benefit Drug Policy
768. Medical Therapies for Enzyme Deficiencies - Community Plan Medical Benefit Drug Policy
769. Entyvio® (Vedolizumab) - Community Plan Medical Benefit Drug Policy
770. Off-Label/Unproven Specialty Drug Treatment - Community Plan Medical Benefit Drug Policy
771. Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) - Community Plan Medical Benefit…
772. Ocrevus® (Ocrelizumab) and Ocrevus Zunovo™ (Ocrelizumab and Hyaluronidase-Ocsq)…
773. Buprenorphine (Probuphine® & Sublocade®) – Community Plan Medical Benefit Drug Policy
774. Exondys 51® (Eteplirsen) - Community Plan Medical Benefit Drug Policy
775. Spinraza® (Nusinersen) - Community Plan Medical Benefit Drug Policy
776. Review at Launch for New to Market Medications - Community Plan Medical Benefit Drug…
777. Radicava® (Edaravone) - Community Plan Medical Benefit Drug Policy
778. Trogarzo® (Ibalizumab-Uiyk) - Community Plan Medical Benefit Drug Policy
779. Luxturna® (Voretigene Neparvovec-Rzyl) - Community Plan Medical Benefit Drug Policy
780. Brineura® (Cerliponase Alfa) - Community Plan Medical Benefit Drug Policy
781. Ilaris® (Canakinumab) - Community Plan Medical Benefit Drug Policy
782. Alpha1-Proteinase Inhibitors - Community Plan Medical Benefit Drug Policy
783. Denosumab - Community Plan Medical Benefit Drug Policy
784. Ryplazim® (Plasminogen, Human-Tvmh) - Community Plan Medical Benefit Drug Policy
785. Crysvita® (Burosumab-Twza) - Community Plan Medical Benefit Drug Policy
786. Ilumya® (Tildrakizumab-Asmn) - Community Plan Medical Benefit Drug Policy
787. Parsabiv® (Etelcalcetide) - Community Plan Medical Benefit Drug Policy
788. Gamifant® (Emapalumab-Lzsg) - Community Plan Medical Benefit Drug Policy
789. Zolgensma® (Onasemnogene Abeparvovec-Xioi) - Community Plan Medical Benefit Drug Policy
790. Zulresso® (Brexanolone) - Community Plan Medical Benefit Drug Policy
791. Krystexxa® (Pegloticase) - Community Plan Medical Benefit Drug Policy
792. Adakveo® (Crizanlizumab-Tmca) - Community Plan Medical Benefit Drug Policy
793. Vyondys 53® (Golodirsen) - Community Plan Medical Benefit Drug Policy
794. Givlaari® (Givosiran) - Community Plan Medical Benefit Drug Policy
795. Tepezza® (Teprotumumab-Trbw) - Community Plan Medical Benefit Drug Policy
796. Vyepti® (Eptinezumab-Jjmr) - Community Plan Medical Benefit Drug Policy
797. Uplizna® (Inebilizumab-Cdon) - Community Plan Medical Benefit Drug Policy
798. Scenesse® (Afamelanotide) - Community Plan Medical Benefit Drug Policy
799. Viltepso® (Viltolarsen) - Community Plan Medical Benefit Drug Policy
800. Enjaymo® (Sutimlimab-Jome) - Community Plan Medical Benefit Drug Policy
801. Evkeeza® (Evinacumab-Dgnb) - Community Plan Medical Benefit Drug Policy
802. Amondys 45® (Casimersen) - Community Plan Medical Benefit Drug Policy
803. Saphnelo® (Anifrolumab-Fnia) - Community Plan Medical Benefit Drug Policy
804. Nplate® (Romiplostim) - Community Plan Medical Benefit Drug Policy
805. Rituximab (Riabni®, Rituxan®, Ruxience®, & Truxima®) - Community Plan Medical Benefit Drug…
806. Leqvio® (Inclisiran) - Community Plan Medical Benefit Drug Policy
807. Tezspire® (Tezepelumab-Ekko) - Community Plan Medical Benefit Drug Policy
808. Skyrizi® (Risankizumab-Rzaa) - Community Plan Medical Benefit Drug Policy
809. Hemgenix® (Etranacogene Dezaparvovec-Drlb) - Community Plan Medical Benefit Drug Policy
810. Erythropoiesis-Stimulating Agents - Community Plan Medical Benefit Drug Policy
811. Oncology Medication Clinical Coverage - Community Plan Medical Benefit Drug Policy
812. Maximum Dosage and Frequency - Community Plan Medical Benefit Drug Policy
813. Immune Globulin (IVIG and SCIG) - Community Plan Medical Benefit Drug Policy
814. Somatostatin Analogs - Community Plan Medical Benefit Drug Policy
815. Stelara® (Ustekinumab) - Community Plan Medical Benefit Drug Policy
816. Simponi Aria® (Golimumab) Injection for Intravenous Infusion - Community Plan Medical…
817. White Blood Cell Colony Stimulating Factors - Community Plan Medical Benefit Drug Policy
818. Ketalar® (Ketamine) and Spravato® (Esketamine) - Community Plan Medical Benefit Drug…
819. RNA-Targeted Therapies (Amvuttra® and Onpattro®) - Community Plan Medical Benefit Drug…
820. Testosterone Replacement or Supplementation Therapy - Community Plan Medical Benefit Drug…
821. Subcutaneous Implantable Naltrexone Pellets - Community Plan Medical Benefit Drug Policy
822. Evenity® (Romosozumab-Aqqg) - Community Plan Medical Benefit Drug Policy
823. Sodium Hyaluronate - Community Plan Medical Benefit Drug Policy
824. Cimzia® (Certolizumab Pegol) - Community Plan Medical Benefit Drug Policy
825. Reblozyl® (Luspatercept-Aamt) - Community Plan Medical Benefit Drug Policy
826. Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) - Community…
827. Antiemetics for Oncology - Community Plan Medical Benefit Drug Policy
828. Xiaflex® (Collagenase Clostridium Histolyticum) - Community Plan Medical Benefit Drug…
829. Oxlumo® (Lumasiran) and Rivfloza® (Nedosiran) - Community Plan Medical Benefit Drug Policy
830. Long-Acting Injectable Antiretroviral Agents for HIV - Community Plan Medical Benefit Drug…
831. Denied Drug Codes - Pharmacy Benefit Drugs (for Arizona Only) - Community Plan Medical…
832. Neonatal Fc Receptor Blockers (Rystiggo®, Vyvgart®, & Vyvgart® Hytrulo) - Community Plan…
833. Tzield® (Teplizumab-Mzwv) - Community Plan Medical Benefit Drug Policy
834. Gene Therapies for Hemophilia B - Community Plan Medical Benefit Drug Policy
835. Briumvi® (Ublituximab-Xiiy) - Community Plan Medical Benefit Drug Policy
836. Qalsody® (Tofersen) - Community Plan Medical Benefit Drug Policy
837. Rebyota® (Fecal Microbiota, Live-Jslm) - Community Plan Medical Benefit Drug Policy
838. Elevidys™ (Delandistrogene Moxparvovec-Rokl) - Community Plan Medical Benefit Drug Policy
839. Vyjuvek® (Beramagene Geperpavec-Svdt) - Community Plan Medical Benefit Drug Policy
840. Veopoz® (Pozelimab-Bbfg) - Community Plan Medical Benefit Drug Policy
841. Omvoh® (Mirikizumab-Mrkz) - Community Plan Medical Benefit Drug Policy
842. Cosentyx® (Secukinumab) - Community Plan Medical Benefit Drug Policy
843. Tocilizumab (Actemra®, Tofidence™, and Tyenne®) - Community Plan Medical Benefit Drug…
844. Buprenorphine (Brixadi® & Sublocade®) - Community Plan Medical Benefit Drug Policy
845. Self-Administered Medications - Community Plan Medical Benefit Drug Policy
846. Roctavian® (Valoctocogene Roxaparvovec-Rvox) - Community Plan Medical Benefit Drug Policy
847. Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease…
848. Ophthalmologic Complement Inhibitors - Community Plan Medical Benefit Drug Policy
849. Spevigo® (Spesolimab-Sbzo) - Community Plan Medical Benefit Drug Policy
850. Adzynma (ADAMTS13, Recombinant-Krhn) - Community Plan Medical Benefit Drug Policy
851. Tremfya® (Guselkumab) - Community Plan Medical Benefit Drug Policy
852. united-healthcare-cs203-bLiposuction for Lipedema - Community Plan Medical Policy
853. united-healthcare-cs203ne-aLiposuction for Lipedema (for Nebraska Only) - Community Plan Medical Policy
854. united-healthcare-cs254-aDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis - Community Plan…
855. united-healthcare-cs254ne-aDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for Nebraska Only)…
856. united-healthcare-cs254nj-aDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for New Jersey…
857. united-healthcare-cs255-aLeft Atrial Appendage Closure (Occlusion) - Community Plan Medical Policy
858. united-healthcare-cs255ne-aLeft Atrial Appendage Closure (Occlusion) (for Nebraska Only) - Community Plan Medical…
859. united-healthcare-cs255nj-aLeft Atrial Appendage Closure (Occlusion) (for New Jersey Only) - Community Plan Medical…
860. united-healthcare-cs329-dPercutaneous Patent Foramen Ovale (PFO) Closure - Community Plan Medical Policy
861. united-healthcare-cs329nj-aPercutaneous Patent Foramen Ovale (PFO) Closure (for New Jersey Only) - Community Plan…
862. united-healthcare-cs330-bPercutaneous Vertebroplasty and Kyphoplasty - Community Plan Medical Policy
863. united-healthcare-cs330nj-bPercutaneous Vertebroplasty and Kyphoplasty (for New Jersey Only) - Community Plan Medical…
864. united-healthcare-cs334-bProstate Surgeries and Interventions - Community Plan Medical Policy
865. united-healthcare-cs334nj-aProstate Surgeries and Interventions (for New Jersey Only) - Community Plan Medical Policy
866. united-healthcare-cs342-fSurgery of the Foot - Community Plan Medical Policy
867. united-healthcare-cs343-fSurgery of the Hand or Wrist - Community Plan Medical Policy
868. united-healthcare-cs354-bCorneal Collagen Cross-Linking - Community Plan Medical Policy
869. united-healthcare-cs355-aSurgery for the Prevention and Treatment of Lymphedema - Community Plan Medical Policy
870. united-healthcare-cs355nj-aSurgical Treatment of Lymphedema (for New Jersey Only) - Community Plan Medical Policy
871. united-healthcare-cs356-aHospital Services: Observation and Inpatient - Community Plan Medical Policy
872. united-healthcare-cs356ne-aHospital Services: Observation and Inpatient (for Nebraska Only) - Community Plan Medical…
873. united-healthcare-cs356nj-aHospital Services: Observation and Inpatient (for New Jersey Only) - Community Plan…
874. united-healthcare-cs357-bWalkers - Community Plan Medical Policy
875. united-healthcare-cs357ne-bWalkers (for Nebraska Only) - Community Plan Medical Policy
876. united-healthcare-cs357nj-bWalkers (for New Jersey Only) - Community Plan Medical Policy
877. united-healthcare-cs358-bSacral Nerve Stimulation for Urinary and Fecal Indications - Community Plan Medical Policy
878. united-healthcare-cs358nj-bSacral Nerve Stimulation for Urinary and Fecal Indications (for New Jersey Only)…
879. united-healthcare-cs360-aUpper Extremity Prosthetic Devices - Community Plan Medical Policy
880. united-healthcare-cs360nj-aUpper Extremity Prosthetic Devices (for New Jersey Only) - Community Plan Medical Policy
881. united-healthcare-cs361-aLower Extremity Prosthetics - Community Plan Medical Policy
882. united-healthcare-cs361nj-aLower Extremity Prosthetics (for New Jersey Only) - Community Plan Medical Policy
883. united-healthcare-cs363-bInterspinous Fusion and Decompression Devices - Community Plan Medical Policy
884. united-healthcare-cs363nj-bInterspinous Fusion and Decompression Devices (for New Jersey Only) - Community Plan…
885. united-healthcare-cs364-bMinimally Invasive Spine Surgery Procedures - Community Plan Medical Policy
886. united-healthcare-cs364nj-bMinimally Invasive Spine Surgery Procedures (for New Jersey Only) - Community Plan Medical…
887. united-healthcare-cs365-bSpinal Fusion and Decompression - Community Plan Medical Policy
888. united-healthcare-cs365nj-bSpinal Fusion and Decompression (for New Jersey Only) - Community Plan Medical Policy
889. united-healthcare-cs367nj-bCorneal Collagen Cross-Linking (for New Jersey Only) - Community Plan Medical Policy
890. united-healthcare-cs368-bFecal Microbiota Transplantation - Community Plan Medical Policy
891. united-healthcare-cs368nj-bFecal Microbiota Transplantation (for New Jersey Only) - Community Plan Medical Policy
892. united-healthcare-cs369-aTransanal Minimally Invasive Surgical Procedures - Community Plan Medical Policy
893. united-healthcare-cs369nj-aTransanal Minimally Invasive Surgical Procedures (for New Jersey Only) - Community Plan…
894. united-healthcare-cs370-aElectroretinography - Community Plan Medical Policy
895. united-healthcare-cs370ne-aElectroretinography (for Nebraska Only) - Community Plan Medical Policy
896. united-healthcare-cs370nj-aElectroretinography (for New Jersey Only) - Community Plan Medical Policy
897. united-healthcare-cs371-aInjectable Dermal Fillers and Bulking Agents - Community Plan Medical Policy
898. united-healthcare-cs371ne-aInjectables for Reconstructive Procedures (for Nebraska Only) - Community Plan Medical…
899. united-healthcare-cs371nj-aInjectables for Reconstructive Procedures (for New Jersey Only) - Community Plan Medical…
900. united-healthcare-cs372-aMolecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment…
901. united-healthcare-cs372ne-aMolecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment…
902. united-healthcare-cs372nj-aMolecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment…
903. united-healthcare-cs373-aMolecular Oncology Companion Diagnostic Testing - Community Plan Medical Policy
904. united-healthcare-cs373-cFDA Cleared or Approved Companion Diagnostic Testing - Community Plan Medical Policy
905. united-healthcare-cs373ne-aMolecular Oncology Companion Diagnostic Testing (for Nebraska Only) - Community Plan…
906. united-healthcare-cs373nj-aMolecular Oncology Companion Diagnostic Testing (for New Jersey Only) - Community Plan…
907. united-healthcare-cs374-aElectrical Stimulation for Wounds - Community Plan Medical Policy
908. united-healthcare-cs374nj-aElectrical Stimulation for Wounds (for New Jersey Only) - Community Plan Medical Policy
909. united-healthcare-cs378-aOcular Photoscreening - Community Plan Medical Policy
910. Exondys 51® (Eteplirsen) (for New Jersey Only) - Community Plan Medical Benefit Drug…
911. Vyondys 53® (Golodirsen) (for New Jersey Only) - Community Plan Medical Benefit Drug…
912. Viltepso® (Viltolarsen) (for New Jersey Only) - Community Plan Medical Benefit Drug Policy
913. Amondys 45® (Casimersen) (for New Jersey Only) - Community Plan Medical Benefit Drug…
914. Ketalar® (Ketamine) and Spravato® (Esketamine) (for New Jersey Only) - Community Plan…
915. united-healthcare-dcg001-08Full Mouth Debridement - Dental Clinical Policy
916. united-healthcare-dcg003-11Medically Necessary Orthodontic Treatment - Dental Clinical Policy
917. united-healthcare-dcg005-07Surgical and Partial Extractions of Erupted Teeth and Removal of Retained Roots - Dental…
918. united-healthcare-dcg007-10Dental Implant Placement and Treatment of Peri-Implant Defects/Disease - Dental Clinical…
919. united-healthcare-dcg008-10Single Tooth Indirect Restorations - Dental Clinical Policy
920. united-healthcare-dcg009-09Non-Surgical Endodontics - Dental Clinical Policy
921. united-healthcare-dcg011-09Coronal Splinting - Dental Clinical Policy
922. united-healthcare-dcg016-12General Anesthesia and Conscious Sedation Services - Dental Clinical Policy
923. united-healthcare-dcg017-09Fixed Prosthodontics - Dental Clinical Policy
924. united-healthcare-dcg019-08Occlusal Guards - Dental Clinical Policy
925. united-healthcare-dcg020-12Removable Prosthodontics - Dental Clinical Policy
926. united-healthcare-dcg021-07Core Buildup, Post and Core, and Pin Retention - Dental Clinical Policy
927. united-healthcare-dcg022-08Non-Surgical Extractions - Dental Clinical Policy
928. united-healthcare-dcg023-07Single Tooth Direct Restorations - Dental Clinical Policy
929. united-healthcare-dcg024-08Other Restorative Procedures - Dental Clinical Policy
930. united-healthcare-dcg025-09Labial Veneers - Dental Clinical Policy
931. united-healthcare-dcg026-07Sealants and Preventive Resin Restorations - Dental Clinical Policy
932. united-healthcare-dcg028-07Oral Surgery: Alveoloplasty and Vestibuloplasty - Dental Clinical Policy
933. united-healthcare-dcg029-08Oral Surgery: Non-Pathologic Excisional Procedures - Dental Clinical Policy
934. united-healthcare-dcg035-07Space Maintenance - Dental Clinical Policy
935. united-healthcare-dcg039-07Bacterial, Viral, and Fungal Testing of Oral Infections - Dental Clinical Policy
936. united-healthcare-dcg043-10Dental Care Services in an Operating Room or Ambulatory Surgery Center - Dental Clinical…
937. united-healthcare-dcg046-01Dental Implant Supported Prostheses - Dental Clinical Policy
938. united-healthcare-dcp004-09Non-Surgical Periodontal Therapy - Dental Clinical Policy
939. united-healthcare-dcp006-08Surgical Extraction of Impacted Teeth - Dental Clinical Policy
940. united-healthcare-dcp010-10Surgical Endodontics - Dental Clinical Policy
941. united-healthcare-dcp012-09Prefabricated Crowns - Dental Clinical Policy
942. united-healthcare-dcp013-10Surgical Periodontics: Resective Procedures - Dental Clinical Policy
943. united-healthcare-dcp014-10Surgical Periodontics: Regenerative Procedures – Dental Clinical Policy
944. united-healthcare-dcp015-09Surgical Periodontics: Mucogingival Procedures - Dental Clinical Policy
945. united-healthcare-dcp018-08Topical Fluoride Treatment – Dental Clinical Policy
946. united-healthcare-dcp018-10Topical Medicaments for Caries Prevention or Remineralization - Dental Clinical Policy
947. united-healthcare-dcp027-09Oral Surgery: Miscellaneous Surgical Procedures - Dental Clinical Policy
948. united-healthcare-dcp032-10Oral Surgery: Orthodontic Related Procedures - Dental Clinical Policy
949. united-healthcare-dcp033-08In-Office Drug Administration and Dispensing of Medications - Dental Clinical Policy
950. united-healthcare-dcp034-09Application of Desensitizing Medicaments and Resins - Dental Clinical Policy
951. united-healthcare-dcp036-07Genetic Testing for Oral Disease - Dental Clinical Policy
952. united-healthcare-dcp037-07Salivary Testing - Dental Clinical Policy
953. united-healthcare-dcp040-08Miscellaneous Diagnostic Procedures - Dental Clinical Policy
954. united-healthcare-dcp041-08Non-Ionizing Diagnostic Procedures - Dental Clinical Policy
955. united-healthcare-dcp044-04Cone Beam Computed Tomography - Dental Clinical Policy
956. united-healthcare-dcp045-05Dental Barrier Membrane Guided Tissue Regeneration - Dental Clinical Policy
957. united-healthcare-dcp047-03Biological Materials for Dental Indications - Dental Clinical Policy
958. united-healthcare-dcp048-02Bone Replacement Grafts - Dental Clinical Policy
959. Treatment of Temporomandibular Joint Disorders - Oxford Clinical Policy
960. Light and Laser Therapy - Oxford Clinical Policy
961. Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes - Oxford Clinical…
962. Genetic Testing for Hereditary Cancer - Oxford Clinical Policy
963. Computerized Dynamic Posturography - Oxford Clinical Policy
964. Sleep Studies - Oxford Clinical Policy
965. Virtual Upper Gastrointestinal Endoscopy - Oxford Clinical Policy
966. Neurophysiologic Testing and Monitoring - Oxford Clinical Policy
967. Fecal Calprotectin Testing - Oxford Clinical Policy
968. Breast Imaging for Screening and Diagnosing Cancer - Oxford Clinical Policy
969. Video Electroencephalographic (vEEG) Monitoring and Recording - Oxford Clinical Policy
970. Genetic Testing for Neuromuscular Disorders - Oxford Clinical Policy
971. Inhaled Nitric Oxide Therapy - Oxford Clinical Policy
972. Diagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis - Oxford Clinical…
973. Electroretinography - Oxford Clinical Policy
974. Ocular Photoscreening - Oxford Clinical Policy
975. Home Hemodialysis - Oxford Clinical Policy
976. united-healthcare-dme-005-27Mechanical Stretching Devices - Oxford Clinical Policy
977. united-healthcare-dme-006-31Electrical and Ultrasound Bone Growth Stimulators - Oxford Clinical Policy
978. united-healthcare-dme-017-24Unicondylar Spacer Devices for Treatment of Pain or Disability - Oxford Clinical Policy
979. united-healthcare-dme-019-39Airway Clearance Devices - Oxford Clinical Policy
980. united-healthcare-dme-021-44Total Artificial Disc Replacement for the Spine - Oxford Clinical Policy
981. united-healthcare-dme-029-24Electromagnetic Therapy for Wounds - Oxford Clinical Policy
982. united-healthcare-dme-035-34Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Oxford…
983. united-healthcare-dme-037-19Pneumatic Compression Devices - Oxford Clinical Policy
984. united-healthcare-dme-039-29Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements - Oxford…
985. united-healthcare-dme-040-10Speech Generating Devices - Oxford Clinical Policy
986. united-healthcare-dme-041-7Pediatric Gait Trainers and Standing Systems - Oxford Clinical Policy
987. united-healthcare-dme-046-7Mobility Devices, Options, and Accessories - Oxford Clinical Policy
988. united-healthcare-dme-047-9Beds and Mattresses - Oxford Clinical Policy
989. united-healthcare-dme-050-7Patient Lifts - Oxford Clinical Policy
990. united-healthcare-dme-051-3Walkers - Oxford Clinical Policy
991. united-healthcare-dme-052-2Enteral Nutrition (Oral and Tube Feeding) - Oxford Clinical Policy
992. united-healthcare-durg042-14National Standardized Dental Claim Review Guidelines (for Commercial Only) - Dental Review…
993. united-healthcare-durg050-01National Standardized Dental Claim Review Guidelines (for Medicare Plans Only) - Dental…
994. united-healthcare-ent-004-36Cochlear Implants - Oxford Clinical Policy
995. united-healthcare-ent-005-40Rhinoplasty and Other Nasal Procedures - Oxford Clinical Policy
996. united-healthcare-ent-007-34Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable - Oxford…
997. united-healthcare-ent-020-22Otoacoustic Emissions Testing - Oxford Clinical Policy
998. united-healthcare-ent-021-16Balloon Sinus Ostial Dilation - Oxford Clinical Policy
999. united-healthcare-ent-021-17Sinus Surgeries and Interventions - Oxford Clinical Policy
1000. united-healthcare-ent-022-14Functional Endoscopic Sinus Surgery (FESS) - Oxford Clinical Policy