Medical policies and criteria: new, updated and reviewed
As Security Health Plan reviews and develops clinical criteria on Medical and Interpretation Policies, we ask providers with particular professional knowledge or clinical expertise on certain subjects for their input and opinions. Requests from providers must be documented on the Provider Input Form. Please download and complete the form, then email the completed form to shp.health.services@securityhealth.org. We appreciate your input.
To receive payment, providers must meet all policy criteria outlined for the specific service provided. Please review the below list of medical policies and request a copy of the policies for any procedures you perform in your office.
Security Health Plan medical policies are updated monthly. To review the medical policy changes click here.
A-D
- 72 Hour Continuous Glucose Monitoring (CGM) Systems In Office
This policy is required for:- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
Abdominoplasty and Panniculectomy
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
Abnormal Vascular Lesion Removal
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Ambulance: Land and Air Transportation
This policy is required for:- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Amino-Acid Based Oral Formulas for Infants
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Autologous Cultured Chondrocytes
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Back Surgical Procedures: Cervical and Thoracic Spinal Levels Inpatient and Outpatient Settings
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Back Surgical Procedures Lumbar Spinal Level Inpatient and Outpatient Settings
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Back Surgical Procedure Vertebroplasty Inpatient and Outpatient Settings
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Blepharoplasty, Blepharoptosis Repair
This policy is required for:- >BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Bone and Tendon Graft Substitutes and Adjuncts
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Bone Growth Stimulator for the 5th Metatarsal
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Botulinum Toxin Injections
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
-
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Breast Reduction Mammoplasty
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Carpal Tunnel Repair Surgical Precertification
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Carpal Tunnel Syndrome Median Neuropathy Specialty Consult
This policy is required for:
- State of Wisconsin Employee Trust Fund
- State of Wisconsin Employee Trust Fund
- Cellular Therapies
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Chelation Therapy
This policy is required for:
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
Chronic Knee Pain-Osteoarthritis or Meniscal Degeneration Specialty Consult
This policy is required for:
- State of Wisconsin Employee Trust Fund
Cluster and Migraine Headache: Nonsurgical Management
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
E-H
- Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Electroconvulsive Therapy
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Electroencephalography EEG Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Erectile Dysfunction Treatments
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Experimental or Investigational
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Eye Movement Desensitization and Reprocessing (EMDR)
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Fecal Microbiota Transplantation FMT
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Femoroacetabular Surgery for Hip Impingement Syndrome
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Gastric Pacing and Gastric Electrical Stimulation
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Gender Reassignment Services and Surgical Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Genetic Testing
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- State of Wisconsin Employee Trust Fund
- Home Care Coverage Criteria
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- State of Wisconsin Employee Trust Fund
- Home Health Care- Medicare Advantage
This policy is required for:
- Medicare Advantage HMO-POS
- Medicare Advantage HMO-POS
- Home Infusion
This policy is required for:
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Hospice Health Services
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Hyperbaric Oxygen Therapy
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Hyperthermic Intraperitoneal Chemotherapy
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Hysterectomy Surgical Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
I-L
Implantable Cardioverter Defibrillator ICD Insertion Procedures
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
This policy is required for:
- State of Wisconsin Employee Trust Fund
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
M-P
- MAZE Procedure
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Medicare Advantage Chiropractor
This policy is required for:
- Medicare Advantage HMO-POS
- Medicare Advantage HMO-POS
- Medicare Advantage Skilled Nursing Facility Coverage Criteria
This policy is required for:
- Medicare Advantage HMO-POS
- Medicare Advantage HMO-POS
- Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Mitraclip Procedure
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Obesity Management, Surgical Approaches
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Oral Appliances for the Treatment of Obstructive Sleep Apnea
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Outpatient and Inpatient Chemotherapy Administration
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Pancreas Transplant Alone (PTA) and Autologous Islet Cell Transplants
This policy is required for:
- Medicare Advantage HMO-POS
- Commercial
- Marshfield Clinic Health System
- State of Wisconsin Employee Trust Fund
- Peripheral Vascular Stents
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Physical, Occupational and Speech Therapy
This policy is required for:
- Private Duty Nursing in the Home Setting
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
Q-T
- Radiesse
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Radiofrequency Ablation Pulmonary Tumor Debulking
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Refractive Eye Surgery
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Septoplasty/Rhinoplasty
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Skin Substitutes, Chemical Peels, Dermabrasions, and other Skin Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Sleep Studies
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Spinal Cord Stimulation
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Swing Bed
This policy is required for:
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Synagis Injections
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- State of Wisconsin Employee Trust Fund
- TMJ Benefit Review
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Tilt Table Testing
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Total Ankle Replacement
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Total Disc Arthroplasty
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Total Hip Replacement Surgical Precertification
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Total Knee Replacement Surgical Precertification
This policy is required for:
- BadgerCare Plus
- Commercial
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Transcatheter Aortic Valve Replacement (TAVR)
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Treatment of Autism Spectrum Disorders
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Treatment of Chronic Skin Conditions
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
U-Z
- Urinary Incontinence
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Vagus Nerve Stimulation for Epilepsy and Depression
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Varicose Vein Treatments
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Wearable Hearing Aids
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund
- Zika Virus
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- State of Wisconsin Employee Trust Fund