Medicaid Medical Policy Search



Name
Type
State
Effective
Electrical Stimulation for Oropharyngeal Dysphagia Medical PolicyPA Medicaid06/01/2022
Skin Replacement Therapy for Chronic Non healing Wounds in the Outpatient Settin Medical PolicyPA Medicaid03/01/2023
Ultrasound Bone Growth Stimulators Medical PolicyPA Medicaid06/01/2022
Capsule Endoscopy Medical PolicyPA Medicaid03/01/2023
Prescription Digital Therapeutics (e.g., reSET and reSET-O) Medical PolicyPA Medicaid06/01/2022
Speech Generating Devices Medical PolicyPA Medicaid03/01/2023
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical PolicyPA Medicaid03/01/2023
Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Medical PolicyPA Medicaid06/01/2022
Negative Pressure Wound Therapy in the Outpatient Setting Medical PolicyPA Medicaid03/01/2023
Panniculectomy/Abdominoplasty/Lipectomy Medical PolicyPA Medicaid03/01/2023
Prostatic Urethral Lift Medical PolicyPA Medicaid03/01/2023
Minimally Invasive Lumbar Decompression (MILD) Medical PolicyPA Medicaid03/01/2023
Testing for Genetic Disease Medical PolicyPA Medicaid06/01/2022
Hypoglossal Nerve Stimulation Implantation in the Treatment of Obstructive Sleep Apnea Medical PolicyPA Medicaid03/01/2023
Ambulance Services – Air Medical PolicyPA Medicaid07/01/2022
Gender Affirmation Services Medical PolicyPA Medicaid07/01/2022
Ultrasound Bone GrowtMultimarker Serum Testing Related to Ovarian Cancerh Stimulators Medical PolicyPA Medicaid07/01/2022
Chromosomal Microarray Analysis (CMA): Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) Medical PolicyPA Medicaid03/01/2023
BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia Medical PolicyPA Medicaid03/01/2023
Bariatric Surgery Medical PolicyPA Medicaid07/01/2022
Pulmonary Rehabilitation (PR) Medical PolicyPA Medicaid07/01/2022
Electrical Bone Growth Stimulators for the Spine (Osteogenesis Stimulators) Medical PolicyPA Medicaid07/01/2022
Cardiac Rehabilitation, Phase II Outpatient Medical PolicyPA Medicaid07/01/2022
Breast Reconstructive Surgery Medical PolicyPA Medicaid03/01/2023
Carpal Tunnel Surgery Medical PolicyPA Medicaid07/01/2022
Enteral Feeding In-Line Cartridge (EFIC™) Medical PolicyPA Medicaid07/01/2022
Deep Brain Stimulation (DBS) Medical PolicyPA Medicaid07/01/2022
Hysterectomy for Benign Conditions Medical PolicyPA Medicaid07/01/2022
Wearable Cardioverter-Defibrillators in the Home Setting Medical PolicyPA Medicaid07/01/2022
Artificial Pancreas Medical PolicyPA Medicaid07/01/2022
Fetal Aneuploidy Testing Using Noninvasive Cell-Free Fetal DNA Medical PolicyPA Medicaid08/01/2022
Scanning Computerized Ophthalmic Diagnostic Imaging Medical PolicyPA Medicaid08/01/2022
Single-use Ambulatory Electrocardiographic Monitors (e.g., Zio Patch) Medical PolicyPA Medicaid08/01/2022
Fecal Microbiota Transplant Medical PolicyPA Medicaid09/01/2022
Gastrointestinal Pathogen Assays Medical PolicyPA Medicaid09/01/2022
Colorectal Cancer Screening Medical PolicyPA Medicaid09/01/2022
Scanning Computerized Ophthalmic Diagnostic Imaging Medical PolicyPA Medicaid09/01/2022
Home Oxygen Therapy (HOT) Medical PolicyPA Medicaid10/01/2022
Ambulance Services – Ground Medical PolicyPA Medicaid10/01/2022
Automated Ambulatory Blood Pressure Monitoring (ABPM) Medical PolicyPA Medicaid10/01/2022
Repetitive Transcranial Magnetic Stimulation Medical PolicyPA Medicaid10/01/2022
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical PolicyPA Medicaid10/03/2023
Deep Bronchial Thermoplasty Medical PolicyPA Medicaid10/01/2022
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC) Medical PolicyPA Medicaid10/01/2022
BRAF Mutation Analysis Medical PolicyPA Medicaid10/01/2022
Genetic Testing for Warfarin and Clopidogrel Therapy Medical PolicyPA Medicaid10/01/2022
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules Medical PolicyPA Medicaid10/01/2022
Upper Gastrointestinal Endoscopy (EGD-esophagogastroduodenoscopy) Medical PolicyPA Medicaid11/01/2022
Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) Medical PolicyPA Medicaid11/01/2022
Gene Expression and Biomarker Prostate Cancer Testing Medical PolicyPA Medicaid11/01/2022
Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis Medical PolicyPA Medicaid11/01/2022
Non-Oncologic Genetic Testing Panels Medical PolicyPA Medicaid11/01/2022
Oncologic Genetic Testing Panels Medical PolicyPA Medicaid11/01/2022
Vitamin D Deficiency Testing Medical PolicyPA Medicaid11/01/2022
Surgical Treatment of Obstructive Sleep Apnea Medical PolicyPA Medicaid11/01/2022
Cardiac Contractility Modulation (CCM) Therapy Medical PolicyPA Medicaid12/01/2022
Bronchial Valves Medical PolicyPA Medicaid12/01/2022
Dual-Energy X-ray Absorptiometry (DXA) for Vertebral Fracture Assessment Medical PolicyPA Medicaid12/01/2022
Exhaled Nitric Oxide Measurement in the Management of Respiratory Disorders Medical PolicyPA Medicaid12/01/2022
Gastric Electrical Stimulation (GES) Medical PolicyPA Medicaid12/01/2022
Cochlear Implants Medical PolicyPA Medicaid12/01/2022
Cosmetic Procedures Medical PolicyPA Medicaid12/01/2022
Hyperbaric Oxygen Therapy (HBOT) Medical PolicyPA Medicaid12/01/2022
Gene Expression Testing for Cancer Treatment (Breast, Colon, Prostate) Medical PolicyPA Medicaid12/01/2022
Bariatric Surgery Medical PolicyPA Medicaid12/01/2022
Prescription Digital Therapeutics (e.g., reSET and reSET-O) Medical PolicyPA Medicaid01/01/2023
Breast Scintimammography Medical PolicyPA Medicaid01/01/2023
Genetic Testing for Cystic Fibrosis Medical PolicyPA Medicaid01/01/2023
Myoelectric Upper Extremity Orthoses Medical PolicyPA Medicaid01/01/2023
Electrical Stimulation for Oropharyngeal Dysphagia Medical PolicyPA Medicaid01/01/2023
Testing for Genetic Disease Medical PolicyPA Medicaid01/01/2023
Passive Oscillatory Devices in the Outpatient Setting Medical PolicyPA Medicaid01/01/2023
Electrical Bone Growth Stimulators (Noninvasive/Invasive, Spinal, & Ultrasound) Medical PolicyPA Medicaid01/01/2023
Single-use Ambulatory Electrocardiographic Monitors (e.g., Zio Patch) Medical PolicyPA Medicaid01/01/2023
Supervised Exercise Therapy (SET) in the Management of Peripheral Artery Disease Medical PolicyPA Medicaid02/01/2023

Highmark Wholecare Policy Disclaimer

  • The Policies neither constitutes nor substitutes for medical advice. Highmark Wholecare’s Policies should not be construed as providing medical advice or treatment or guaranteeing the outcome or results of any medical services/treatments and/or procedures Providers are responsible for providing medical advice and treatment, are independent contractors, and are not employees or agents of Highmark Wholecare. If members have a specific question about their medical condition, they should consult with their provider.
  • In the event of a conflict between the Policy and Member Handbook or Evidence of Coverage, the express terms of the Member Handbook or Evidence of Coverage will govern. The existence of a medical guideline is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the medical guideline.  The Policies are used in making decisions as to medical necessity only and they do not guarantee payment of services. Policies serve as one of the sets of guidelines for coverage decisions.
  • The information on this website may not reflect a recent policy change or all of the applicable medical guidelines.


This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

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