Medical and Drug Policies
The Medical Policies, Medical Benefit Drug Policies, and corresponding update bulletins for UnitedHealthcare Community Plan of Ohio are listed below.
A monthly notice of recently approved and/or revised Medical Policies and Medical Benefit Drug Policies is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device, or procedure) in the Medical Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medical Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
02/01/2025 – Community Plan of Ohio Medical Policy Update Bulletin: February 2025
Last Published 02.01.2025
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Ohio Medical Policies and/or Medical Benefit Drug Policies.
03/01/2025 – Community Plan of Ohio Medical Policy Update Bulletin: March 2025
Last Published 03.01.2025
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Ohio Medical Policies and/or Medical Benefit Drug Policies.
04/01/2025 – Community Plan of Ohio Medical Policy Update Bulletin: April 2025
Last Published 04.01.2025
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Ohio Medical Policies and/or Medical Benefit Drug Policies.
Community Plan of Ohio Medical Policy Update Bulletin Archive
Last Published 04.01.2025
A listing of archived Medical Policy Update Bulletins.
Current Policies
Community Plan of Ohio Medical & Drug Policies Terms and Conditions
Please read the terms and conditions below carefully.
UnitedHealthcare has developed Medical Policies and Medical Benefit Drug Policies to assist us in administering health benefits. These policies are provided for informational purposes and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Our Medical Policies and Medical Benefit Drug Policies express our determination of whether a health service (e.g., test, device, or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.
Benefit coverage for health services is determined by the specific benefit plan. When deciding coverage, the federal, state, or contractual requirements for benefit plan coverage must be referenced. In the event of a conflict, the federal, state, or contractual requirements for benefit plan coverage supersede these policies.
Medical Policies and Medical Benefit Drug Policies are developed as needed, regularly reviewed and updated, and subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. UnitedHealthcare Medical Policies and Medical Benefit Drug Policies are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
Medical Policies and Medical Benefit Drug Policies are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to Change Healthcare and are not published on this website.
When these policies are used to determine medical necessity, clinical guidelines will be applied in the following order:
- State/Federal Guidelines and Contract Requirements
- InterQual® criteria
- UnitedHealthcare Community Plan of Ohio Medical & Drug Policies
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Ablative Treatment for Spinal Pain (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64628, 64629, 64999.
Abnormal Uterine Bleeding and Uterine Fibroids (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the endometrial ablation, the use of levonorgestrel-releasing intrauterine devices (LNG-IUDs), uterine artery embolization (UAE), and magnetic resonance-guided focused ultrasound ablation (MRgFUS). Applicable Procedure Codes: 0071T, 0072T, 37243, 58563, J7296, J7297, J7298, J7301, J7306, S4981.
Adakveo® (Crizanlizumab-Tmca) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of Adakveo® (crizanlizumab-tmca) to reduce the frequency of vasoocclusive crises in patients with sickle cell disease. Applicable Procedure Code: J0791.
Adzynma (ADAMTS13, Recombinant-Krhn) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses the use of Adzynma (ADAMTS13, recombinant-krhn) for the treatment of congenital thrombotic thrombocytopenic purpura (cTTP). Applicable Procedure Code: J7171.
Airway Clearance Devices (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, acoustical or mechanical percussor, positive expiratory pressure and aerosol drug delivery system combination device, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7021, A7025, A7026, E0469, E0481, E0483.
Ambulance Services (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Amondys 45® (Casimersen) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Amondys 45® (casimersen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1426.
Apheresis (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Athletic Pubalgia Surgery (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 27299, 49659, 49999.
Autologous Cellular Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 0717T, 0718T, 27599.
Bariatric Surgery (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Beds and Mattresses (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses hospital beds, mattresses, and accessories. Applicable Procedure Codes: E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0316, E0328, E0329, E0910, E0911, E1399.
Benlysta® (Belimumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Applicable Procedure Code: J0490.
Botulinum Toxins A and B (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588, J0589.
Breast Imaging for Screening and Diagnosing Cancer (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses breast imaging for screening and diagnosing cancer. Applicable Procedure Codes: 0422T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, S8080.
Breast Reconstruction (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses breast reconstruction services. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Breast Reduction Surgery (for Ohio Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Brineura® (Cerliponase Alfa) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.
Briumvi® (Ublituximab-Xiiy) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Briumvi® (ublituximab-xiiy) for the treatment of relapsing forms of multiple sclerosis (MS). Applicable Procedure Code: J2329.
Bronchial Thermoplasty (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Brow Ptosis and Eyelid Repair (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses brow ptosis, browpexy or internal browlift, eyelid surgery for correction of lagophthalmos, lid retraction surgery, and canthoplasty/canthopexy. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Cardiac Event Monitoring (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0650T, 0902T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93297, 93298, 93799, E0616, E1399.
Cardiovascular Disease Risk Tests (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0019M, 0052U, 0308U, 0309U, 0377U, 0415U, 82172, 83695, 83698, 83701, 83704, 84999, 93050, 93799, 93895, 93998.
Carrier Testing Panels for Genetic Diseases (for Ohio Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 0400U, 81412, 81443, 81479.
Catheter Ablation for Atrial Fibrillation (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.
Cell-Free Fetal DNA Testing (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0327U, 0488U, 0489U, 0494U, 81420, 81422, 81479, 81507.
Chelation Therapy for Non-Overload Conditions (for Ohio Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J3520, J8499, M0300, S9355.
Chemotherapy Observation or Inpatient Hospitalization (for Ohio Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses chemotherapy observation or overnight (inpatient) stay.
Chromosome Microarray Testing (Non-Oncology Conditions) (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 0156U, 0209U, 81228, 81229, 81349, 81479, S3870.
Cochlear Implants (for Ohio Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Cognitive Rehabilitation (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.
Collagen Crosslinks and Biochemical Markers of Bone Turnover (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Complement Inhibitors (PiaSky®, Soliris®, & Ultomiris®) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of PiaSky® (crovalimab-akkz), Soliris® (eculizumab), and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: C9399, J1300, J1303, J3490, J3590.
Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedure Codes: 0054T, 0055T, 20985, 27599.
Computerized Dynamic Posturography (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Continuous Glucose Monitor (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4238, A9276, A9277, A9278, E2102, G0564, G0565, S1030, S1031.
Core Decompression for Avascular Necrosis (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Cosmetic and Reconstructive Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses cosmetic and reconstructive procedures.
Crysvita® (Burosumab-Twza) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.
Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Deep Brain and Cortical Stimulation (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses conventional deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 61889, 61891, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Denosumab (Prolia® & Xgeva®) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.
Diagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses dynamic spinal visualization techniques and vertebral motion analysis. Applicable Procedure Codes: 0693T, 76120, 76125, 76496, 76499.
Diagnostic Spinal Ultrasonography (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Code: 76800.
Discogenic Pain Treatment (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses thermal intradiscal procedures (TIPs) and percutaneous discectomy and decompression procedures for treating discogenic pain, and annulus fibrosus repair following spinal surgery. Applicable Procedure Codes: 0627T, 0628T, 0629T, 0630T, 22526, 22527, 22899, S2348.
Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Ohio Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses durable medical equipment (DME), orthotics, medical supplies, and repairs/replacements.
Elective Inpatient Services (for Ohio Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Electric Tumor Treatment Field Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766, E0767.
Electrical and Ultrasound Bone Growth Stimulators (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 0720T, 0783T, 63650, 63655, 63663, 63664, 63685, 64555, 64596, 64597, 64598, 64999, A4438, A4543, A4544, A4556, A4557, A4593, A4594, A4595, E0720, E0721, E0730, E0731, E0743, E0744, E0745, E0764, E0770, E1399, L8678, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Electrical Stimulation for Wounds (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses electrical stimulation for the treatment of wounds. Applicable Procedure Codes: G0281, G0282.
Electromagnetic Therapy for Wounds (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses electromagnetic therapy for ulcers or wounds. Applicable Procedure Codes: E0769, G0295, G0329.
Electroretinography (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses multifocal electroretinogram (mfERG), pattern electroretinogram (PERG), and pattern electroretinogram optimized for glaucoma screening (PERGLA). Applicable Procedure Codes: 0509T, 92274.
Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Enjaymo® (Sutimlimab-Jome) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Enjaymo® (sutimlimab-jome) for the treatment of cold agglutinin disease (CAD). Applicable Procedure Code: J1302.
Enteral Nutrition (Oral and Tube Feeding) (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses oral and enteral nutrition. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9432, S9433, S9434, S9435.
Epidural Steroid Injections for Spinal Pain (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.
Epiduroscopy, Epidural Lysis of Adhesions, and Discography (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses functional anesthetic discography (FAD), provocative discography, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 62291, 62292, 64999, 72285, 72295.
Erythropoiesis-Stimulating Agents (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa), Epogen® (epoetin alfa), Mircera® (methoxy polyethylene glycol-epoetin beta [MPG-epoetin beta]), Procrit® (epoetin alfa), and Retacrit™ (epoetin alfa). Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106.
Evenity® (Romosozumab-Aqqg) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Evenity® (romosozumab-aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedure Code: J3111.
Evkeeza® (Evinacumab-Dgnb) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Evkeeza® (evinacumab-dgnb) for the treatment of homozygous familial hypercholesterolemia (HoFH). Applicable Procedure Code: J1305.
Exondys 51® (Eteplirsen) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 0864T, 28890.
Facet Joint and Medial Branch Block Injections for Spinal Pain (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses facet joint injections/medial branch blocks for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495.
FDA Cleared or Approved Companion Diagnostic Testing (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses companion diagnostic testing for oncology indications. Applicable Procedure Codes: 0022U, 0037U, 0179U, 0239U, 0242U, 0473U, 81445, 81449, 81450, 81451, 81455, 81456, 81479, 81599.
Fecal Microbiota Transplantation (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 05.01.2024 – This policy addresses fecal microbiota transplantation (FMT) via enema for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Codes: 0780T, 44705, G0455.
Gamifant® (Emapalumab-Lzsg) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.
Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 0779T, 0868T, 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 74270, 76496, 91117, 91120, 91122, 91132, 91133, A9286, A9900, A9999, E1399.
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0369U, 87505, 87506, 87507.
Gender Dysphoria Treatment (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Genetic Testing for Cardiac Disease (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 0401U, 0439U, 0440U, 0466U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.
Genetic Testing for Hereditary Cancer (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing. Applicable Procedure Codes: 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0138U, 0162U, 0238U, 0474U, 0475U, 81162, 81163, 81164, 81432, 81433, 81435, 81436, 81437, 81438.
Genetic Testing for Neuromuscular Disorders (for Ohio Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 0417U, 81440, 81448, 81460, 81465, 81479.
Givlaari® (Givosiran) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.
Glaucoma Surgical Treatments (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 65820, 66174, 66175, 66179, 66180, 66183, 66989, 66991, L8612.
Gonadotropin Releasing Hormone Analogs (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 01.01.2024 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J1951, J1952, J3315, J3316, J9155, J9202, J9217, J9225, J9226.
Gynecomastia Surgery (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses surgical treatment of gynecomastia. Applicable Procedure Code: 19300.
Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses outpatient and inpatient habilitative services and outpatient rehabilitation services.
Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable (for Ohio Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Hereditary Angioedema (HAE), Treatment and Prophylaxis (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophlaxis of hereditary angioedema (HAE).
Home Health, Skilled, and Custodial Care (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses home health, skilled, and custodial care services.
Home Hemodialysis (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Home Traction Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Hospital Services: Observation and Inpatient (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses hospital services for observation versus inpatient level of care.
Hysterectomy (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
Ilaris® (Canakinumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Ilaris® (canakinumab). Applicable Procedure Code: J0638.
Immune Globulin (IVIG and SCIG) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.
Immunomodulatory Agents for Systemic Inflammatory Diseases (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 02.01.2025 – This policy addresses immunomodulatory agents, including Actemra® (tocilizumab), Cimzia® (certolizumab pegol), Cosentyx® (secukinumab), Entyvio® (vedolizumab), Ilumya® (tildrakizumab-asmn), Omvoh® (mirikizumab-mrkz), Orencia® (abatacept), Skyrizi® (risankizumab‐rzaa), and Stelara® (ustekinumab), for systemic inflammatory diseases.
Implanted Electrical Stimulator for the Spinal Cord (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Infliximab (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of infliximab products, including Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb), Remicade® (infliximab), and Renflexis® (infliximab-abda). Applicable Procedure Codes: J1745, Q5103, Q5104, Q5109, Q5121.
Inhaled Nitric Oxide Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.
Injectable Dermal Fillers and Bulking Agents (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses dermal filler injections and injectable bulking agents. Applicable Procedure Codes: G0429, L8607, Q2026, Q2028.
Insulin Delivery for Managing Diabetes (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses insulin delivery for diabetes management. Applicable Procedure Codes: A4226, A9274, E0784, E0787, S1034, S1035, S1036, S1037.
Intensity-Modulated Radiation Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Interspinous Fusion and Decompression Devices (for Ohio Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 04.01.2024 – This policy addresses interspinous bony fusion devices and decompression systems. Applicable Procedure Codes: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 22899, C1821.
Intrauterine Fetal Surgery (for Ohio Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.
Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: J1437, J1439, Q0138, Q0139.
Korsuva® (Difelikefalin) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Korsuva® (difelikefalin) for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis. Applicable Procedure Code: J0879.
Krystexxa® (Pegloticase) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.
Left Atrial Appendage Closure (Occlusion) (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses closure (occlusion) of the left atrial appendage (LAA). Applicable Procedure Codes: 33267, 33268, 33269, 33340, 33999.
Lemtrada® (Alemtuzumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Lemtrada® (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.
Leqvio® (Inclisiran) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses the use of Leqvio® (inclisiran) for the treatment of heterozygous familial hypercholesterolemia (HeFH) and clinical atherosclerotic cardiovascular disease (ASCVD). Applicable Procedure Code: J1306.
Light and Laser Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 0479T, 0480T, 17106, 17107, 17108, 17999, 96999.
Liposuction for Lipedema (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses liposuction for lipedema when used to treat functional impairment. Applicable Procedure Codes: 15877, 15878, 15879.
Lithotripsy for Salivary Stones (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Lower Extremity Endovascular Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses lower extremity endovascular procedures. Applicable Procedure Codes: 0238T, 0505T, 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235.
Lower Extremity Prosthetics (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses lower extremity prosthetics.
Luxturna® (Voretigene Neparvovec-Rzyl) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Luxturna® (voretigene neparvovec-rzyl) for the treatment of inherited retinal dystrophies (IRD) caused by mutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene. Applicable Procedure Code: J3398.
Macular Degeneration Treatment Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, epiretinal radiation therapy, and laser photocoagulation. Applicable Procedure Codes: 0308T, 0378T, 0379T, 67036, 67299, 92499.
Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses covered routine patient costs during qualified clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Manipulation Under Anesthesia (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Manipulative Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Maximum Dosage and Frequency (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.
Mechanical Stretching Devices (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1803, E1804, E1805, E1806, E1807, E1808, E1810, E1811, E1812, E1813, E1814, E1815, E1816, E1818, E1822, E1823, E1825, E1826, E1827, E1828, E1829, E1830, E1831, E1840, E1841.
Medical Therapies for Enzyme Deficiencies (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: C9399, J0180, J0217, J0221, J1203, J1322, J1458, J1743, J1931, J2508, J2840, J3397, J3490, J3590.
Minimally Invasive Procedures for Gastric and Esophageal Diseases (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses minimally invasive procedures for gastric and esophageal diseases. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43497, 43499, 43999.
Minimally Invasive Spine Surgery Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses minimally invasive spine surgery procedures. Applicable Procedure Codes: 0200T, 0201T, 0275T, 22586, 22630, 22899, 62287, 62380, G0276.
Mobility Devices, Options, and Accessories (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses manual wheelchairs, power mobility devices, wheelchair options and accessories, and seating systems.
Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses molecular oncology testing for hematologic cancer. Applicable Procedure Codes: 0017M, 0050U, 0120U, 0171U, 0298U, 0299U, 0300U, 0331U, 0364U, 0413U, 0485U, 81195, 81450, 81451, 81455, 81456, 81479, 81599.
Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 03.01.2025 – This policy addresses molecular oncology testing for solid tumor cancers, including breast cancer, prostate cancer, thyroid cancer, hematological cancer, lung cancer, and uveal melanoma.
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of monoclonal antibodies directed against amyloid, including Aduhelm® (aducanumab-avwa), Kisunla™ (Donanemab-Azbt), and Leqembi® (lecanemab-irmb), for the treatment of Alzheimer’s disease. Applicable Procedure Codes: J0172, J0174, J0175.
Motorized Spinal Traction (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Negative Pressure Wound Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Neonatal Fc Receptor Blockers (Vyvgart®, Vyvgart® Hytrulo, & Rystiggo®) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Vyvgart®, Vyvgart® Hytrulo, & Rystiggo® for the treatment of myasthenia gravis. Applicable Procedure Codes: J9333, J9334.
Nerve Graft to Restore Erectile Function During Radical Prostatectomy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Neurophysiologic Testing and Monitoring (for Ohio Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses nerve conduction studies and other neurophysiological testing.
Neuropsychological Testing Under the Medical Benefit (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Noncontact Warming Therapy, Ultrasound Therapy, and Fluorescence Imaging for Wounds (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 0598T, 0599T, 97610, A6000, E0231, E0232.
Nplate® (Romiplostim) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of Nplate® (romiplostim) for the treatment of chronic immune thrombocytopenic purpura (ITP). Applicable Procedure Code: J2802.
Obstructive and Central Sleep Apnea Treatment (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA).
Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses occipital neuralgia and headache treatments, including occipital nerve blocks and occipital nerve ablation. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64596, 64597, 64598, 64633, 64634, 64722, 64744, 64771, 64999, A4540, L8679, L8680, L8685.
Ocrevus® (Ocrelizumab) and Ocrevus Zunovo™ (Ocrelizumab and Hyaluronidase-Ocsq) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses the use of Ocrevus® (ocrelizumab) and Ocrevus Zunovo™ (ocrelizumab and hyaluronidase-ocsq) for the treatment of multiple sclerosis. Applicable Procedure Codes: C9399, J2350, J3490, J3590.
Ocular Photoscreening (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses instrument-based ocular photoscreening and retinal birefringence scanning/retinal polarization scanning. Applicable Procedure Codes: 0469T, 99174, 99177.
Off-Label/Unproven/New FDA Indication Specialty Drug Treatment (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.
Omnibus Codes (for Ohio Only)– Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses multiple services/procedures.
Oncology Medication Clinical Coverage (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: J0640, J0641, J0642, J1323, J9198, J9199, J9201, J9205, J9206, J9324, J9380.
Ophthalmologic Complement Inhibitors (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses the use of Izervay™ (avacincaptad pegol) and Syfovre™ (pegcetacoplan injection) for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Applicable Procedure Codes: J2781, J2782.
Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0177, J0178, J0179, J2777, J2778, J2779, J9035, Q5124, Q5128.
Orthognathic (Jaw) Surgery (for Ohio Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses orthognathic (jaw) surgery.
Outpatient Surgical Procedures – Site of Service (for Ohio Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the medical necessity of certain planned surgical procedures when performed in a hospital outpatient department.
Oxlumo® (Lumasiran) and Rivfloza™ (Nedosiran) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of Oxlumo® (lumasiran) and Rivfloza™ (nedosiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedures Codes: C9399, J0224, J3490.
Panniculectomy and Body Contouring Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Parsabiv® (Etelcalcetide) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Patient Lifts (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses patient lifts. Applicable Procedure Codes: E0621, E0630, E0635, E0636, E0639, E0640, E1035, E1036.
Pectus Deformity Repair (for Ohio Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Pediatric Gait Trainers and Standing Systems (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses pediatric gait trainers and standing systems. Applicable Procedure Codes: E0637, E0638, E0641, E0642, E8000, E8001, E8002.
Percutaneous Patent Foramen Ovale (PFO) Closure (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.
Percutaneous Vertebroplasty and Kyphoplasty (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.
Pharmacogenetic Panel Testing (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses pharmacogenetic multi-gene panel testing. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 0345U, 0347U, 0348U, 0349U, 0350U, 0380U, 0392U, 0411U, 0419U, 0423U, 0434U, 0438U, 0456U, 0460U, 0461U, 81418, 81479.
Plagiocephaly and Craniosynostosis Treatment (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: D5924, L0112, L0113, S1040.
Pneumatic Compression Devices (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Preimplantation Genetic Testing and Related Services (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses preimplantation genetic testing (PGT) and related services. Applicable Procedure Codes: 0254U, 58970, 58974, 76948, 81228, 81229, 81349, 81479, 81479, 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89342, 89352, S4011, S4015, S4016, S4022, S4037.
Private Duty Nursing Services (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses private duty nursing services. Applicable Procedure Codes: S9123, S9124, T1000, T1001.
Prolotherapy and Platelet Rich Plasma Therapies (for Ohio Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, G0460, G0465, M0076, P9020.
Prostate Surgeries and Interventions (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses prostate surgeries and interventions, including transurethral ablation, cryoablation, surgical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, and transperineal placement of biodegradable material. Applicable Procedure Codes: 0421T, 0582T, 0619T, 0655T, 0714T, 0738T, 0739T, 0867T, 37243, 52441, 52442, 53850, 53852, 53854, 53855, 55873, 55874.
Proton Beam Radiation Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Provider Administered Drugs – Site of Care (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses outpatient hospital facility-based intravenous medication infusion.
Qalsody® (Tofersen) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Qalsody® (tofersen) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1304.
Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses radiation therapy fractionation, image-guided radiation therapy (IGRT), and special radiation therapy services. Applicable Procedure Codes: 77014, 77331, 77370, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77470, 77520, 77522, 77523, 77525, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.
Radicava® (Edaravone) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Reblozyl® (Luspatercept-Aamt) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic syndromes or myelodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.
Repository Corticotropin Injections (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of repository corticotropin injections (Acthar® Gel and Purified Cortophin Gel™). Applicable Procedure Code: J0800.
Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of interleukin-5 (IL-5) antagonists, including Cinqair® (reslizumab), Fasenra® (benralizumab), and Nucala® (mepolizumab).
Review at Launch for New to Market Medications (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 02.01.2025 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Rhinoplasty and Other Nasal Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, and nasal polypectomy. Applicable Procedure Codes: 30117, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30469, 30999, 31237, 31242, 31243, 64999, L8699.
Rituximab (Riabni®, Rituxan®, Ruxience®, & Truxima®) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Riabni® (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J9312, Q5115, Q5119, Q5123.
RNA-Targeted Therapies (Amvuttra® and Onpattro®) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses the use of Onpattro® (patisiran) and Amvuttra® (vutrisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedure Codes: J0222, J0225.
Ryplazim® (Plasminogen, Human-Tvmh) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Code: J2998.
Sacral Nerve Stimulation for Urinary and Fecal Indications (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses sacral nerve stimulation for urinary and fecal indications. Applicable Procedure Codes: 0784T, 0785T, 0786T, 0787T, 64561, 64581, 64585, 64590, 64595, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Saphnelo® (Anifrolumab-Fnia) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses Saphnelo® (anifrolumab-fnia) for the treatment of moderate to severe systemic lupus erythematosus (SLE). Applicable Procedure Code: J0491
Self-Administered Medications (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses medications that are determined to be self-administered and excluded from medical coverage.
Sensory Integration Therapy and Auditory Integration Training (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Simponi Aria® (Golimumab) Injection for Intravenous Infusion (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses Simponi Aria® (golimumab) injection for intravenous infusion for the treatment of ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Applicable Procedure Code: J1602.
Sinus Surgeries and Interventions (for Ohio Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS), and self-expanding absorptive sinus ostial dilation. Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 31299.
Skin and Soft Tissue Substitutes (for Ohio Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses skin and soft tissue substitutes.
Sleep Studies (for Ohio Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Sodium Hyaluronate (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Somatostatin Analogs (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of somatostatin analogs, including Sandostatin® (octreotide acetate), Sandostatin® LAR (octreotide acetate LAR), Signifor® (pasireotide diaspartate), Signifor® LAR (pasireotide), and Somatuline® Depot (lanreotide). Applicable Procedure Codes: J1930, J1932, J2353, J2354, J2502.
Speech Generating Devices (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses speech generating devices. Applicable Procedure Codes: E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599.
Spevigo® (Spesolimab-Sbzo) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Spevigo® (spesolimab-sbzo) for the treatment of generalized pustular psoriasis (GPP). Applicable Procedure Code: J1747.
Spinal Fusion and Bone Healing Enhancement Products (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses spinal fusion enhancement products. Applicable Procedure Codes: 0814T, 20930, 20931, 20939, 22899.
Spinal Fusion and Decompression (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses spinal fusion and decompression procedures, laminectomy, isolated facet fusion, dynamic stabilization systems, and total facet joint arthroplasty.
Spinraza® (Nusinersen) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of Spinraza® (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.
Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses stereotactic radiation therapy, including stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Applicable Procedures Codes: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77371, 77372, 77373, 77432, 77435, G0339, G0340, G0563.
Surgery for the Prevention and Treatment of Lymphedema (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses surgical procedures for the treatment or prevention of lymphedema. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 38999, 49906.
Surgery of the Elbow (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 29830, 29834, 29835, 29836, 29837, 29838.
Surgery of the Foot (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses surgery of the foot. Applicable Procedure Codes: 28285, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28899, 29893.
Surgery of the Hand or Wrist (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses surgery of the hand or wrist. Applicable Procedure Codes: 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 29840, 29843, 29844, 29845, 29846, 29847.
Surgery of the Hip (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.
Surgery of the Knee (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses surgery of the knee.
Surgery of the Shoulder (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23470, 23472, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29999.
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses varicose vein ablative and stripping procedures, ligation procedures, ambulatory phlebectomy, and other procedures for varicose veins and venous insufficiency. Applicable Procedure Codes: 0744T, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37765, 37766, 37780, 37785, 37799.
Synagis® (Palivizumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Synagis® (palivizumab) to prevent serious respiratory syncytial virus disease (RSV) in high risk infants and young children. Applicable Procedure Code: 90378.
Tepezza® (Teprotumumab-Trbw) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.
Testosterone Replacement or Supplementation Therapy (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of injectable testosterone and testosterone pellets for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone.
Tezspire® (Tezepelumab-Ekko) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Tezspire® (tezepelumab) for the treatment of severe asthma.
Total Artificial Disc Replacement for the Spine (for Ohio Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 03.01.2024 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0098T, 0165T, 22856, 22857, 22858, 22860, 22861, 22862, 22899.
Transanal Minimally Invasive Surgical Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses transanal endoscopic microsurgery (TEMS) and transanal minimally invasive surgery (TAMIS). Applicable Procedure Code: 0184T.
Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Ohio Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 75894, 79445, S2095.
Transcatheter Heart Valve Procedures (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33418, 33419, 33477, 33999, 93799.
Transcranial Magnetic Stimulation (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 0858T, 64999, 90867, 90868, 90869.
Transpupillary Thermotherapy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Treatment of Temporomandibular Joint Disorders (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21198, 21209, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Tysabri® (Natalizumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Tysabri® (natalizumab) for the treatment of relapsing forms of multiple sclerosis and Crohn's disease. Applicable Procedure Code: J2323.
Tzield® (Teplizumab-Mzwv) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Tzield® (teplizumab-mzwv) to delay the onset of stage 3 type 1 diabetes. Applicable Procedure Code: J9381.
Umbilical Cord Blood Harvesting and Storage for Future Use (for Ohio Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Unicondylar Spacer Devices for Treatment of Pain or Disability (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Uplizna® (Inebilizumab-Cdon) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedure Code: J1823.
Upper Extremity Prosthetic Devices (for Ohio Only) – Community Plan Medical Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses upper extremity prosthetic devices. Applicable Procedure Codes: L6026, L6611, L6621, L6629, L6632, L6677, L6680, L6682, L6686, L6687, L6688, L6694, L6695, L6696, L6697, L6698, L6715, L6880, L6881, L6882, L6883, L6884, L6890, L6925, L6935, L6945, L6955, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L7259, L7360, L7364, L7366, L7367, L7368, L7400, L7401, L7403, L7404, L8465.
Vagus and External Trigeminal Nerve Stimulation (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 61886, 64553, 64568, 64570, A4541, E0733, E0735, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Veopoz™ (Pozelimab-Bbfg) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Veopoz™ (pozelimab-bbfg) for the treatment of CD55-deficient protein-losing enteropathy (PLE) (i.e., CHAPLE disease). Applicable Procedure Code: J9376.
Vertebral Body Tethering for Scoliosis (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Codes: 0656T, 0657T, 0790T, 22836, 22837, 22838, 22899.
Video Electroencephalographic (vEEG) Monitoring and Recording (for Ohio Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses video electroencephalographic (vEEG) monitoring and recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Viltepso® (Viltolarsen) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses Viltepso® (viltolarsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1427.
Virtual Upper Gastrointestinal Endoscopy (for Ohio Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Vision Services Not Routinely Covered (for Ohio Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses vision services that are not routinely covered. Applicable Procedure Codes: V2025, V2399, V2499, V2531, V2630, V2631, V2632, V2702, V2750, V2756, V2761, V2762, V2780, V2781, V2784, V2786, V2788, V2797.
Visual Information Processing Evaluation and Orthoptic and Vision Therapy (for Ohio Only) – Community Plan Medical Policy
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92066, 92499.
Vyepti® (Eptinezumab-Jjmr) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Vyepti® (eptinezumab-jjmr) for the treatment of chronic and episodic migraine. Applicable Procedure Code: J3032.
Vyjuvek® (Beramagene Geperpavec-Svdt) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Vyjuvek® (beramagene geperpavec-svdt) for the treatment of wounds in patients with dystrophic epidermolysis bullosa (DEB). Applicable Procedure Code: J3401.
Vyondys 53® (Golodirsen) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Vyondys 53® (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1429.
Walkers (for Ohio Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of walkers. Applicable Procedure Codes: A4636, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159.
White Blood Cell Colony Stimulating Factors (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 01.01.2024 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Udenyca, Zarxio, and Ziextenzo. Applicable Procedure Codes: C9096, J1442, J1447, J1449, J2506, J2820, J3490, J3590, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5127, Q5130.
Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Ohio Only) – Community Plan Medical Policy
Last Published 04.01.2025
Effective Date: 10.01.2024 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0036U, 0094U, 0212U, 0213U, 0214U, 0215U, 0265U, 0335U, 0336U, 0425U, 0426U, 0454U, 0469U, 81415, 81416, 81417, 81425, 81426, 81427.
Xolair® (Omalizumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy
Last Published 04.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of Xolair® (omalizumab) for subcutaneous use for the treatment of moderate to severe persistent asthma, chronic urticaria, and nasal polyps.