Medical
Prior Authorization Guidelines
Allergy Testing/Immunotherapy
- Allergy Immunotherapy Medical Guideline (Updated 10/1/25)
- Allergy Testing Guidelines (Updated 10/1/25)
Alzheimer Biomarker Testing
- Alzheimer Biomarker Testing Guidelines (Effective 10/1/25)
Bariatric Surgery
Doula Services
High Risk OB (HROB)
- HROB Guidelines (Updated 1/1/26)
In-Home Nursing Services
- Additional Home Health Visits (Updated 3/1/25)
- Hospice Services (Updated 11/19/25)
- Paid Family Caregiver Services
- Private Duty Nursing (PDN) Services
Pain Management-Chiropractic and Physical Therapy Services for Adults
- Chiropractic Services Guideline (Updated 3/15/25)
- Physical Therapy Adult Pain Management Guideline (Updated 3/15/25)
Procedure/Surgery Information
- Actinotherapy Guidelines (Updated 6/10/24)
- Corneal Crosslinking (Effective 10/1/25)
- Cosmetic vs Recontructive Guideline (Updated 3/25/25)
- Dermatologic Laser Treatment (Updated 11/1/25)
- Doppler-Middle Cerebral Artery (Updated 12/1/25)
- EEG - Digital Analysis Guideline (Updated 3/1/25)
- EEG - Long Term Electoencephalographic Monitoring
- Leadless Cardiac Pacemaker System (Updated 4/1/26)
- Ocular Amniotic Membrane without Sutures (Effective 3/17/25)
- Panniculectomy Guidelines (Updated 3/7/25)
- Routine Coverage in Clinical Trials (Updated 3/26/25)
- SI Joint Fusion Guidelines (Updated 3/27/24)
- TBI Guidelines (Updated 3/25/25)
- Transcervical Ablation of Uterine Fibroid(s) Sonata System (effective 2/1/26)
- Transplant Guideline
- Viscosupplementation Guidelines (Updated 3/1/26)
- Vulvectomy Labiaplasty Guidelines (Updated 3/25/25)
Psychological/Neuropsychological Testing for Medical Providers
Stimulators
- Diaphragmatic Phrenic Nerve Stimulator Guidelines (Updated 3/8/24)
- Gastric Electrical Stimulation Guidelines (Updated 3/27/24)
- Non-invasive Osteogenic Stimulators Guidelines (updated 1/15/25)
- Peripheral Nerve Stimulator Guidelines (Updated 3/27/24)
- Sacral Nerve Simulator Guidelines (Updated 3/27/24)
- Vagal Nerve Stimulation Guidelines (Updated 11/1/25)
Urine Drug Screens
Wound Care
- Wound Care and Skin Substitutes (Updated 3/25/25)
Ventricular Assist
- Ventricular Assist Device (Updated 11/1/25)
Last Modified on
Apr 08, 2026
