Medicaid Medical Policy Search

Name	Type	State	Effective
Electrical Stimulation for Oropharyngeal Dysphagia	Medical Policy	PA Medicaid	06/01/2022
Skin Replacement Therapy for Chronic Non healing Wounds in the Outpatient Settin	Medical Policy	PA Medicaid	03/01/2023
Capsule Endoscopy	Medical Policy	PA Medicaid	03/01/2023
Prescription Digital Therapeutics (e.g., reSET and reSET-O)	Medical Policy	PA Medicaid	06/01/2022
Speech Generating Devices	Medical Policy	PA Medicaid	03/01/2023
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders	Medical Policy	PA Medicaid	03/01/2023
Magnetic Resonance-Guided Focused Ultrasound (MRgFUS)	Medical Policy	PA Medicaid	04/01/2023
Negative Pressure Wound Therapy in the Outpatient Setting	Medical Policy	PA Medicaid	03/01/2023
Panniculectomy/Abdominoplasty/Lipectomy	Medical Policy	PA Medicaid	03/01/2023
Prostatic Urethral Lift	Medical Policy	PA Medicaid	03/01/2023
Minimally Invasive Lumbar Decompression (MILD)	Medical Policy	PA Medicaid	03/01/2023
Testing for Genetic Disease	Medical Policy	PA Medicaid	06/01/2022
Hypoglossal Nerve Stimulation Implantation in the Treatment of Obstructive Sleep Apnea	Medical Policy	PA Medicaid	03/01/2023
Ambulance Services – Air	Medical Policy	PA Medicaid	04/01/2023
Gender Affirmation Services	Medical Policy	PA Medicaid	04/01/2023
Ultrasound Bone GrowtMultimarker Serum Testing Related to Ovarian Cancerh Stimulators	Medical Policy	PA Medicaid	05/01/2023
Chromosomal Microarray Analysis (CMA): Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP)	Medical Policy	PA Medicaid	03/01/2023
BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia	Medical Policy	PA Medicaid	03/01/2023
Bariatric Surgery	Medical Policy	PA Medicaid	05/01/2023
Pulmonary Rehabilitation (PR)	Medical Policy	PA Medicaid	05/01/2023
Cardiac Rehabilitation, Phase II Outpatient	Medical Policy	PA Medicaid	07/01/2022
Breast Reconstructive Surgery	Medical Policy	PA Medicaid	06/01/2023
Carpal Tunnel Surgery	Medical Policy	PA Medicaid	06/01/2023
Enteral Feeding In-Line Cartridge (EFIC™)	Medical Policy	PA Medicaid	07/01/2022
Deep Brain Stimulation (DBS)	Medical Policy	PA Medicaid	07/01/2022
Hysterectomy for Benign Conditions	Medical Policy	PA Medicaid	07/01/2022
Wearable Cardioverter-Defibrillators in the Home Setting	Medical Policy	PA Medicaid	07/01/2022
Artificial Pancreas	Medical Policy	PA Medicaid	07/01/2022
Fetal Aneuploidy Testing Using Noninvasive Cell-Free Fetal DNA	Medical Policy	PA Medicaid	08/01/2022
Scanning Computerized Ophthalmic Diagnostic Imaging	Medical Policy	PA Medicaid	08/01/2022
Single-use Ambulatory Electrocardiographic Monitors (e.g., Zio Patch)	Medical Policy	PA Medicaid	08/01/2022
Fecal Microbiota Transplant	Medical Policy	PA Medicaid	09/01/2022
Gastrointestinal Pathogen Assays	Medical Policy	PA Medicaid	04/01/2023
Colorectal Cancer Screening	Medical Policy	PA Medicaid	09/01/2022
Scanning Computerized Ophthalmic Diagnostic Imaging	Medical Policy	PA Medicaid	09/01/2022
Home Oxygen Therapy (HOT)	Medical Policy	PA Medicaid	10/01/2022
Ambulance Services – Ground	Medical Policy	PA Medicaid	10/01/2022
Automated Ambulatory Blood Pressure Monitoring (ABPM)	Medical Policy	PA Medicaid	10/01/2022
Repetitive Transcranial Magnetic Stimulation	Medical Policy	PA Medicaid	10/01/2022
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders	Medical Policy	PA Medicaid	10/03/2023
Deep Bronchial Thermoplasty	Medical Policy	PA Medicaid	10/01/2022
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC)	Medical Policy	PA Medicaid	10/01/2022
BRAF Mutation Analysis	Medical Policy	PA Medicaid	10/01/2022
Genetic Testing for Warfarin and Clopidogrel Therapy	Medical Policy	PA Medicaid	10/01/2022
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules	Medical Policy	PA Medicaid	10/01/2022
Upper Gastrointestinal Endoscopy (EGD-esophagogastroduodenoscopy)	Medical Policy	PA Medicaid	11/01/2022
Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP)	Medical Policy	PA Medicaid	11/01/2022
Gene Expression and Biomarker Prostate Cancer Testing	Medical Policy	PA Medicaid	11/01/2022
Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis	Medical Policy	PA Medicaid	11/01/2022
Non-Oncologic Genetic Testing Panels	Medical Policy	PA Medicaid	11/01/2022
Oncologic Genetic Testing Panels	Medical Policy	PA Medicaid	11/01/2022
Vitamin D Deficiency Testing	Medical Policy	PA Medicaid	11/01/2022
Surgical Treatment of Obstructive Sleep Apnea	Medical Policy	PA Medicaid	11/01/2022
Cardiac Contractility Modulation (CCM) Therapy	Medical Policy	PA Medicaid	12/01/2022
Bronchial Valves	Medical Policy	PA Medicaid	12/01/2022
Dual-Energy X-ray Absorptiometry (DXA) for Vertebral Fracture Assessment	Medical Policy	PA Medicaid	12/01/2022
Exhaled Nitric Oxide Measurement in the Management of Respiratory Disorders	Medical Policy	PA Medicaid	12/01/2022
Gastric Electrical Stimulation (GES)	Medical Policy	PA Medicaid	12/01/2022
Cochlear Implants	Medical Policy	PA Medicaid	12/01/2022
Cosmetic Procedures	Medical Policy	PA Medicaid	12/01/2022
Hyperbaric Oxygen Therapy (HBOT)	Medical Policy	PA Medicaid	12/01/2022
Gene Expression Testing for Cancer Treatment (Breast, Colon, Prostate)	Medical Policy	PA Medicaid	12/01/2022
Bariatric Surgery	Medical Policy	PA Medicaid	12/01/2022
Prescription Digital Therapeutics (e.g., reSET and reSET-O)	Medical Policy	PA Medicaid	01/01/2023
Breast Scintimammography	Medical Policy	PA Medicaid	01/01/2023
Genetic Testing for Cystic Fibrosis	Medical Policy	PA Medicaid	01/01/2023
Myoelectric Upper Extremity Orthoses	Medical Policy	PA Medicaid	01/01/2023
Electrical Stimulation for Oropharyngeal Dysphagia	Medical Policy	PA Medicaid	01/01/2023
Testing for Genetic Disease	Medical Policy	PA Medicaid	01/01/2023
Passive Oscillatory Devices in the Outpatient Setting	Medical Policy	PA Medicaid	01/01/2023
Electrical Bone Growth Stimulators (Noninvasive/Invasive, Spinal, & Ultrasound)	Medical Policy	PA Medicaid	01/01/2023
Single-use Ambulatory Electrocardiographic Monitors (e.g., Zio Patch)	Medical Policy	PA Medicaid	01/01/2023
Supervised Exercise Therapy (SET) in the Management of Peripheral Artery Disease	Medical Policy	PA Medicaid	02/01/2023
BRCA1 and BRCA2 Genetic Mutation Testing	Medical Policy	PA Medicaid	06/01/2023

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.

Medicaid Medical Policy Search

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