| Ablation of Peripheral Nerves to Treat Pain | IV-130 · Effective Mar 30, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Ablation Procedures for Treatment of Chronic Rhinitis | IV-170 · Effective Jun 29, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Absorbable Nasal Implant for Treatment of Nasal Valve Collapse | IV-165 · Effective Feb 2, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Actigraphy | II-127 · Effective Oct 27, 2025 · Commercial, Medicaid | 1 | Original policy ↗ |
| Acupuncture | III-01 · Effective Aug 31, 2026 · Commercial, Medicaid | 6 | Original policy ↗ |
| Adjunctive Techniques for Screening and Surveillance of Barrett’s Esophagus and Esophageal Dysplasia | VI-61 · Effective Oct 6, 2025 · Commercial, Medicaid | 6 | Original policy ↗ |
| Air Ambulance | II-160 · Effective Dec 1, 2025 · Commercial, Medicaid | 6 | Original policy ↗ |
| Amino Acid-Based Elemental Formulas | II-69 · Effective Sep 28, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Amniotic Membrane and Amniotic Fluid | IV-145 · Effective Feb 2, 2026 · Commercial, Medicaid | 253 | Original policy ↗ |
| Anesthesia Services for Dental Procedures | II-166 · Effective Dec 1, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Angioplasty and/or Stenting for Intracranial Aneurysms and Atherosclerosis | IV-48 · Effective Sep 28, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Aqueous Shunts and Stents for Glaucoma | IV-146 · Effective Mar 30, 2026 · Commercial, Medicaid | 12 | Original policy ↗ |
| Artificial Intervertebral Discs | IV-46 · Effective Sep 28, 2026 · Commercial, Medicaid | 9 | Original policy ↗ |
| Artificial Retinal Devices | IV-154 · Effective Oct 27, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Autism Spectrum Disorder: Assessment and Early Intensive Behavioral Intervention | X-43 · Effective Feb 2, 2026 · Commercial, Medicaid | 20 | Original policy ↗ |
| Automated Point-of-Care Nerve Conduction Tests | VII-12 · Effective Apr 27, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Autonomic Nervous System Function Testing | II-86 · Effective Mar 30, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Axial (Percutaneous) Lumbar Interbody Fusion | IV-91 · Effective Apr 27, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Balloon Dilation of the Eustachian Tube | IV-162 · Effective Sep 28, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Balloon Ostial Dilation | IV-01 · Effective Sep 28, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Bariatric Surgery | IV-19 · Effective Nov 3, 2025 · Commercial, Medicaid | 23 | Original policy ↗ |
| Baroreflex Stimulation Devices | IV-139 · Effective Dec 1, 2025 · Commercial, Medicaid | 9 | Original policy ↗ |
| Bioengineered Skin and Soft Tissue Substitutes | IV-137 · Effective Jul 27, 2026 · Commercial, Medicaid | 166 | Original policy ↗ |
| Biofeedback | II-70 · Effective Oct 27, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Bioimpedance Spectroscopy Devices for Detection and Management of Lymphedema | II-148 · Effective Feb 2, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Blepharoplasty and Brow Ptosis Repair | IV-17 · Effective Jun 1, 2026 · Commercial, Medicaid | 11 | Original policy ↗ |
| Bone Growth Stimulators for Non-Spinal Indications | II-110 · Effective Jul 27, 2026 · Commercial, Medicaid | 6 | Original policy ↗ |
| Bone Morphogenetic Protein (BMP) | IV-85 · Effective Mar 30, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Breast Ductal Lavage and Fiberoptic Ductoscopy | IV-108 · Effective Sep 28, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Breast Implant, Removal or Replacement | IV-14 · Effective Sep 28, 2026 · Commercial, Medicaid | 9 | Original policy ↗ |
| Bronchial Thermoplasty | IV-117 · Effective Oct 27, 2025 · Commercial, Medicaid | 2 | Original policy ↗ |
| Bunionectomy | IV-171 · Effective Jul 27, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting | II-43 · Effective Oct 27, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Cardiovascular Disease Risk Assessment and Management: Laboratory Evaluation of Non-Traditional Lipid and Nonlipid Biomarkers | VI-24 · Effective Oct 27, 2025 · Commercial, Medicaid | 11 | Original policy ↗ |
| Carpal Tunnel Decompression | IV-176 · Effective Apr 27, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Chelation Therapy | II-03 · Effective Jun 29, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Chiropractic Services | III-04 · Effective Oct 27, 2025 · Commercial, Medicaid | 41 | Original policy ↗ |
| Closure Devices for Atrial Septal Defects and Patent Foramen Ovale | IV-143 · Effective Mar 30, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Cognitive Rehabilitation | III-03 · Effective Jun 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Composite Tissue Allotransplantation of the Hand and Face | IV-151 · Effective Apr 6, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Compression Devices in the Outpatient or Home Setting | II-60 · Effective Jul 27, 2026 · Commercial, Medicaid | 27 | Original policy ↗ |
| Computerized Dynamic Posturography | II-108 · Effective Jul 27, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Confocal Laser Endomicroscopy | II-191 · Effective Mar 2, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Continuous Glucose Monitoring Systems | VII-05 · Effective Jan 5, 2026 · Commercial, Medicaid | 19 | Original policy ↗ |
| Corneal Collagen Cross-Linking | II-207 · Effective Sep 28, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Cosmetic Criteria for Services Which Are Not Addressed by a Specific Medical Policy | XI-04 · Effective Apr 27, 2026 · Commercial, Medicaid | — | Original policy ↗ |
| Coverage of Routine Care Related to Clinical Trials | II-19 · Effective Aug 31, 2026 · Commercial, Medicaid | — | Original policy ↗ |
| Cranial Electrotherapy Stimulation | X-32 · Effective Jul 27, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Cryoablation of Solid Tumors | IV-05 · Effective Oct 27, 2025 · Commercial, Medicaid | 10 | Original policy ↗ |
| Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis | II-155 · Effective Jul 27, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
