Medicare Medical Policy Search

Please access the Gateway Health Provider Portal via Navinet to determine if a drug/HCPCS code requires authorization and to submit authorization requests. View drug authorization requirements/submit authorization requests here:

Cochlear Implantation (NCD 50.3) Medical PolicyPA Medicare05/01/2023
Acupuncture for Chronic Low Back Pain (NCD 30.3.3) Medical PolicyPA Medicare06/01/2022
4Kscore Test Algorithm (L37792) Medical PolicyPA Medicare04/01/2023
Cardiac Event Detection Monitoring (L34953) Medical PolicyPA Medicare04/01/2023
Cardiac Rhythm Device Evaluation (L34833) Medical PolicyPA Medicare04/01/2023
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350) Medical PolicyPA Medicare04/01/2023
Micro-Invasive Glaucoma Surgery (MIGS) (L38223) Medical PolicyPA Medicare04/01/2023
Peripheral Nerve Stimulation (L37360) Medical PolicyPA Medicare04/01/2023
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (LCD 34998) Medical PolicyPA Medicare05/01/2023
Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (160.7.1 & 160.7) Medical PolicyPA Medicare03/01/2023
Blood Glucose Testing (NCD 190.20) Medical PolicyPA Medicare03/01/2023
Fecal Microbiota Transplant Medical PolicyPA Medicare03/01/2023
Speech-Generating Devices (L33739) Medical PolicyPA Medicare03/01/2023
Cataract Extraction (including Complex Cataract Surgery) Medical PolicyPA Medicare04/01/2023
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (L38229) Medical PolicyPA Medicare05/01/2023
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38385) Medical PolicyPA Medicare04/01/2023
Spinal Cord Stimulation (Dorsal Column Stimulation) (L35450) Medical PolicyPA Medicare04/01/2023
Electrocardiographic Services (NCD 20.15) Medical PolicyPA Medicare04/01/2023
Automatic External Defibrillators (AED) (L33690) Medical PolicyPA Medicare07/01/2022
Vitamin D Deficiency Screening Medical PolicyPA Medicare07/01/2022
Scanning Computerized Ophthalmic Diagnostic Imaging (L35038) Medical PolicyPA Medicare08/01/2022
Non-Invasive Peripheral Venous Studies (L35451) Medical PolicyPA Medicare08/01/2022
Percutaneous Transluminal Angioplasty (PTA) (NCD 20.7) Medical PolicyPA Medicare08/01/2022
Pulmonary Rehabilitation (PR) Medical PolicyPA Medicare08/01/2022
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) Medical PolicyPA Medicare09/01/2022
Cosmetic and Reconstructive Surgery (L35090) Medical PolicyPA Medicare09/01/2022
Ambulatory Blood Pressure Monitor (NCD 20.19) Medical PolicyPA Medicare10/01/2022
Ambulance Services (Ground) (L35162) Medical PolicyPA Medicare10/01/2022
Ambulance Services (Air) Medical PolicyPA Medicare10/01/2022
Bronchial Thermoplasty Medical PolicyPA Medicare10/01/2022
Carpal Tunnel Surgery Medical PolicyPA Medicare10/01/2022
Home Oxygen Therapy (L33797) Medical PolicyPA Medicare10/01/2022
Negative Pressure Wound Therapy (NPWT) Pumps (L33821) Medical PolicyPA Medicare11/01/2022
Observation Care (Hospital Outpatient) Medical PolicyPA Medicare11/01/2022
Testing for Genetic Disease Medical PolicyPA Medicare12/01/2022
Pharmacogenomic Testing for Warfarin Response (NCD 90.1) Medical PolicyPA Medicare12/01/2022
Osteogenic Stimulators (150.2) Medical PolicyPA Medicare12/01/2022
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (L38495)Medical PolicyPA Medicare01/01/2023
Acupuncture for Chronic Low Back Pain (NCD 30.3.3) Medical PolicyPA Medicare01/01/2023
Biomarkers Overview (L35062) Medical PolicyPA Medicare01/01/2023
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (NCD 20.35)Medical PolicyPA Medicare01/01/2023
Hyperbaric Oxygen Therapy (HBOT) (NCD 20.29) Medical PolicyPA Medicare01/01/2023
Ambulance Services (Ground) (L35162)Medical PolicyPA Medicare02/01/2023
Implantable Continuous Glucose Monitors (I-CGM) (L38617) Medical PolicyPA Medicare02/01/2023

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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