Policy Guidelines for Medicare Advantage Plans (2024)

Ambulatory EEG Monitoring – Medicare Advantage Policy Guideline

This policy addresses ambulatory electroencephalogram (EEG) monitoring to diagnose neurological conditions. Applicable Procedure Codes: 95700, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726.

Anterior Segment Aqueous Drainage Device – Medicare Advantage Policy Guideline

This policy addresses the use of an anterior segment aqueous drainage device without extraocular reservoir. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 66183, 66189, 66991.

Avastin® (Bevacizumab) – Medicare Advantage Policy Guideline

This policy addresses the use of Avastin® (bevacizumab) for cancer and ophthalmology indications. Applicable Procedure Codes: C9142, C9257, J3590, J7999, J9035, Q5107, Q5118, Q5126, Q5129.

Biomarkers in Cardiovascular Risk Assessment – Medicare Advantage Policy Guideline

This policy addresses the use of biomarkers in cardiovascular (CV) risk assessment. Applicable Procedure Codes: 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141.

Blepharoplasty, Blepharoptosis, and Brow Lift – Medicare Advantage Policy Guideline

This policy addresses blepharoplasty, blepharoptosis, and lid reconstruction. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924.

Blood Product Molecular Antigen Typing – Medicare Advantage Policy Guideline

This policy addresses blood product molecular antigen typing. Applicable Procedure Codes: 0001U, 0084U, 0180U, 0181U, 0182U, 0183U, 184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0221U, 0222U, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112.

Blood-Derived Products for Chronic Non-Healing Wounds (NCD 270.3) – Medicare Advantage Policy Guideline

This policy addresses blood-derived products for chronic non-healing wounds. Applicable Procedure Codes: G0460, G0465.

Capsule Endoscopy – Medicare Advantage Policy Guideline

This policy addresses capsule endoscopy and wireless gastrointestinal motility monitoring systems. Applicable Procedure Codes: 91110, 91111, 91112, 91113, 91299.

Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs – Medicare Advantage Policy Guideline

This policy addresses cardiac rehabilitation programs and intensive cardiac rehabilitation programs for chronic heart failure. Applicable Procedure Codes: 93797, 93798 G0422, G0423.

Category III CPT Codes – Medicare Advantage Policy Guideline

This policy addresses Category III CPT codes used to track the utilization of emerging technologies, services, and procedures.

Clinical Diagnostic Laboratory Services – Medicare Advantage Policy Guideline

This policy addresses clinical diagnostic and preventive laboratory services and screenings.

Corneal Topography – Medicare Advantage Policy Guideline

This policy addresses computerized corneal topography. Applicable Procedure Code: 92025.

Coronary Fractional Flow Reserve Using Computed Tomography (FFR-ct) – Medicare Advantage Policy Guideline

This policy addresses coronary fractional flow reserve using computed tomography (FFR-CT) for the evaluation of coronary artery disease (CAD), including the HeartFlow® FFRct technology. Applicable Procedure Codes: 0501T, 0502T, 0503T, 0504T and 75580.

Cosmetic and Reconstructive Services and Procedures – Medicare Advantage Policy Guideline

This policy addresses cosmetic, reconstructive, and plastic surgery services and procedures.

Diagnostic Radiology Services – Medicare Advantage Policy Guideline

This policy addresses diagnostic radiology services.

Erbitux® (Cetuximab) – Medicare Advantage Policy Guideline

This policy addresses the use of Erbitux® (cetuximab) for the treatment of colorectal cancer and head and neck cancer. Applicable Procedure Code: J9055.

Eylea® (Aflibercept) – Medicare Advantage Policy Guideline

This policy addresses the use of Eylea® (aflibercept). Applicable Procedure Code: J0178.

Gender Dysphoria and Gender Reassignment Surgery (NCD 140.9) – Medicare Advantage Policy Guideline

This policy addresses gender reassignment surgery for members with gender dysphoria.

Genetic Testing for Cardiovascular Disease – Medicare Advantage Policy Guideline

This policy addresses genetic testing for hereditary cardiovascular disease. Applicable Procedure Codes: 0119U, 0237U, 81161, 81410, 81411, 81413, 81414, 81415, 81416, 81417, 81439, 81442.

Genetic Testing for Hereditary Cancer – Medicare Advantage Policy Guideline

This policy addresses genetic testing for hereditary cancer. Applicable Procedure Codes: 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0158U, 0159U, 0160U, 0161U, 0162U, 0238U, 81162, 81163, 81164, 81165, 81166

Halaven® (Eribulin Mesylate) – Medicare Advantage Policy Guideline

This policy addresses the use of Halaven® (eribulin mesylate). Applicable Procedure Code: J9179.

Hemophilia Clotting Factors and Products – Medicare Advantage Policy Guideline

This policy addresses self-administered blood clotting factors and anti-inhibitor coagulant complex (AICC) for the treatment of hemophilia. Applicable Procedure Codes: J7170, J7175, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212.

Immune Globulin – Medicare Advantage Policy Guideline

This policy addresses intravenous immune globulin (IVIG). Applicable Procedure Codes: C0972, J1459, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599, Q2052.

Intravitreal Corticosteroid Implants – Medicare Advantage Policy Guideline

This policy addresses intravitreal corticosteroid implants, including Iluvien® (fluocinolone acetonide intravitreal implant). Applicable Procedure Code: J7313.

Jevtana® (Cabazitaxel) – Medicare Advantage Policy Guideline

This policy addresses the use of Jevtana® (cabazitaxel) for the treatment for hormone-refractory metastatic prostate cancer. Applicable Procedure Code: J9043.

Long-Term Wearable Electrocardiographic Monitoring – Medicare Advantage Policy Guideline

This policy addresses long-term wearable electrocardiographic monitoring. Applicable Procedure Codes: 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272.

Lucentis® (Ranibizumab) – Medicare Advantage Policy Guideline

This policy addresses the use of Lucentis® (ranibizumab) for the treatment of macular degeneration and macular edema. Applicable Procedure Codes: J2778, Q5124, Q5128.

Minimally Invasive Gastroesophageal Reflux Disease (GERD) Procedures – Medicare Advantage Policy Guideline

This policy addresses transoral incisionless fundoplication surgery (TIF) and endoluminal treatment for gastroesophageal reflux disease. Applicable Procedures Codes: 43210, 43257, 43284, 43289, 43499, 43999, 49999.

Molecular Diagnostic Infectious Disease Testing – Medicare Advantage Policy Guideline

This policy addresses molecular diagnostic testing for infectious diseases, including deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) based analysis.

Molecular Pathology/Genetic Testing Reported with Unlisted Codes – Medicare Advantage Policy Guideline

This policy addresses molecular pathology and genetic testing when reported with unlisted codes. Applicable Procedure Codes: 81479, 81599, 84999.

Molecular Pathology/Molecular Diagnostics/Genetic Testing – Medicare Advantage Policy Guideline

This policy addresses molecular and genetic tests that have proven efficacy in the diagnosis or treatment of medical conditions.

Ocular Telescope – Medicare Advantage Policy Guideline

This policy addresses intraocular telescope (implantable miniature telescope [IMT]) for treatment related to end-stage age-related macular degeneration. Applicable Procedure Codes: 0308T, C1840.

Osteopathic Manipulations (OMT) – Medicare Advantage Policy Guideline

This policy addresses electrical and ultrasonic osteogenic stimulators. Applicable Procedure Codes: E0747, E0748, E0749, E0760.

Percutaneous Coronary Interventions – Medicare Advantage Policy Guideline

This policy addresses percutaneous coronary intervention (PCI). Applicable Procedure Codes: 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92973, 92974, 92975, 92978, 92979, 93571, 93572, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608.

Percutaneous or Minimally Invasive Surgical Fusion of the Sacroiliac Joint – Medicare Advantage Policy Guideline

This policy addresses percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain. Applicable Procedure Code: 27279.

Percutaneous Ventricular Assist Device – Medicare Advantage Policy Guideline

This policy addresses percutaneous insertion of an endovascular cardiac (ventricular) assist device. Applicable Procedure Codes: 33990, 33991, 33992, 33993, 33995, 33997.

Pharmacogenomics Testing – Medicare Advantage Policy Guideline

This policy addresses pharmacogenomics testing (PGx). Applicable Procedure Codes: 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0392U, 0423U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0117U, 0173U, 0175U, 0193U, 0286U, 0345U, 0380U, 0411U, 0419U, 81220, 81225, 81226, 81227, 81230, 81231, 81232, 81247, 81283, 81306, 81328, 81335, 81346, 81350, 81355, 81374, 81377, 81381, 81383, 81418.

Platelet Rich Plasma Injections for Non-Wound Injections – Medicare Advantage Policy Guideline

This policy addresses platelet rich plasma injections/applications for the treatment of musculoskeletal injuries or joint conditions. Applicable Procedure Codes: M0076, P9020.

Pneumatic Compression Devices (NCD 280.6) – Medicare Advantage Policy Guideline

This policy addresses pneumatic devices for the treatment of lymphedema and for chronic venous insufficiency with venous stasis ulcers. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.

Porcine Skin and Gradient Pressure Dressings – Medicare Advantage Policy Guideline

This policy addresses porcine (pig) skin dressings and gradient pressure dressings. Applicable Procedure Codes: A2001, A2004, A2008, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6545, A6549, Q4102, Q4103, Q4118, Q4124, Q4135, Q4136, Q4166, Q4175, Q4195, Q4196, Q4197, Q4203.

Positron Emission Tomography (PET) Scan – Medicare Advantage Policy Guideline

This policy addresses positron emission tomography (PET) scans.

Posturography – Medicare Advantage Policy Guideline

This policy addresses computerized dynamic posturography (CDP) for the treatment of neurologic disease and inherited disorders, peripheral vestibular disorders, and disequilibrium in the aging/elderly. Applicable Procedure Code: 92548.

Self-Administered Drug(s) (SAD) – Medicare Advantage Policy Guideline

This policy addresses drugs or biologicals that are usually self-administered by the patient.

Sleep Testing for Obstructive Sleep Apnea (OSA) (NCD 240.4.1) – Medicare Advantage Policy Guideline

This policy addresses sleep testing for obstructive sleep apnea (OSA). Applicable Procedure Codes: 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.

Spinal Cord Stimulators for Chronic Pain – Medicare Advantage Policy Guideline

This policy addresses the implantation of spinal cord stimulators (SCS) for the relief of chronic intractable pain. Applicable Procedure Codes: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688.

Spravato® (Esketamine) – Medicare Advantage Policy Guideline

This policy addresses the use of Spravato® (Esketamine) for the treatment of treatment-resistant depression (TRD) in adults. Applicable Procedure Codes: G2082, G2083.

Testosterone Pellets (Testopel®) – Medicare Advantage Policy Guideline

This policy addresses injectable testosterone pellets (Testopel®). Applicable Procedure Codes: 11980, J3490.

Tier 2 Molecular Pathology Procedures – Medicare Advantage Policy Guideline

This policy addresses Tier 2 molecular pathology procedures, which are procedures not identified by Tier 1 molecular pathology procedures or other CPT codes. Applicable Procedure Codes: 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408.

Transcutaneous Electrical Nerve Stimulation (TENS) – Medicare Advantage Policy Guideline

This policy addresses transcutaneous electrical nerve stimulation (TENS) for the relief of acute post-operative pain, chronic pain other than low back pain, and chronic low back pain. Applicable Procedure Codes: A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731.

Transportation Services – Medicare Advantage Policy Guideline

This policy addresses transportation services, including emergency ambulance services (ground), non-emergency (scheduled) ambulance service (ground), emergency air ambulance transportation, and ambulance service to a physician's office.

Vaccination (Immunization) – Medicare Advantage Policy Guideline

This policy addresses vaccinations/immunizations.

Vitamin D Testing – Medicare Advantage Policy Guideline

This policy addresses testing for vitamin D deficiency. Applicable Procedure Codes: 82306, 82652.

Xgeva®, Prolia® (Denosumab) – Medicare Advantage Policy Guideline

This policy addresses the use of Xgeva®, Prolia® (denosumab) for the treatment of osteoporosis in postmenopausal women with a high risk of bone fractures. Applicable Procedure Code: J0897.

Xofigo® Radioactive Therapeutic Agent – Medicare Advantage Policy Guideline

This policy addresses the use of Xofigo® (radium Ra 223 dichloride) injection for the treatment of castration-resistant prostate cancer (CRPC), symptomatic bone metastases, and no known visceral metastatic disease. Applicable Procedure Codes: 79101, A9606.

This policy addresses the use of zoledronic acid (Zometa® & Reclast®). Applicable Procedure Code: J3489.