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Provider Manual

Medical Policies

Last Updated on February 21, 2019

Policy changes effective December 1, 2018:

Annual policy for the month of December 1, 2018:

(Reviewed with no changes made to medical criteria)

  • Abdominoplasty and Panniculectomy
  • Erectile Dysfunction Treatments
  • Inpatient Admission Prior to Surgery (Pre-op)
  • Radiesse
  • Experimental or Investigational
  • Blepharoplasty, Blepharoptosis Repair
  • Contact Lenses and Other Eyewear
  • Idiopathic Scoliosis
  • Varicose Vein Treatments

(Reviewed with changes made to medical criteria)

  • Experimental or Investigational
  • Breast Reconstruction Post-Mastectomy
  • Treatment of Autism Spectrum Disorders

New Policies - none

Policy changes effective November 1, 2018

Annual policy for the month of November 1, 2018:

(Reviewed with no changes made to medical criteria)

  • Carpal Tunnel Repair Surgical Precertification
  • Carpal Tunnel Syndrome-Median Neuropathy Specialty Consult
  • Chronic Knee Pain-Osteoarthritis or Meniscal Degeneration Specialty Consult
  • Disabled Dependent Coverage
  • Hysterectomy Surgical Procedures
  • Knee Arthroscopy Surgery Precertification
  • Obesity Management, Surgical Approaches Obesity Management
  • Dupixent

 (Reviewed with changes made to medical criteria)

New Policies - none