| Hematopoietic Stem Cell Transplantation for Solid Tumors of Childhood | II-131 · Effective Aug 31, 2026 · Commercial, Medicaid | 17 | Original policy ↗ |
| Hematopoietic Stem Cell Transplantation in the Treatment of Germ-Cell Tumors | II-114 · Effective Aug 31, 2026 · Commercial, Medicaid | 20 | Original policy ↗ |
| Hip Arthroplasty (Hip Replacement) and Hip Resurfacing | IV-107 · Effective Sep 28, 2026 · Commercial, Medicaid | 6 | Original policy ↗ |
| Humanitarian Use Devices | IV-11 · Effective Sep 29, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Hyperbaric Oxygen Therapy | II-04 · Effective Sep 29, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Hypnotherapy | III-02 · Effective Jul 27, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Hysterectomy Surgery for Non-Malignant Conditions | IV-168 · Effective Jul 27, 2026 · Commercial, Medicaid | 28 | Original policy ↗ |
| Image-Guided Minimally Invasive Decompression for Spinal Stenosis | IV-120 · Effective Jun 29, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Implantable Ambulatory Cardiac Event Monitors and Intracardiac Ischemia Monitoring Systems | II-224 · Effective Aug 3, 2026 · Commercial, Medicaid | 10 | Original policy ↗ |
| Implantable Bone Conduction and Bone-Anchored Hearing Aids | IV-178 · Effective Mar 2, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Implantable Middle Ear Hearing Aids (Semi-Implantable and Fully Implantable) for Moderate to Severe Sensorineural Hearing Loss | IV-37 · Effective Oct 27, 2025 · Commercial, Medicaid | 8 | Original policy ↗ |
| Implantable Shock Absorber for the Knee | IV-186 · Effective Sep 7, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Implanted Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea | IV-80 · Effective Sep 28, 2026 · Commercial, Medicaid | 21 | Original policy ↗ |
| In Vitro Chemoresistance and Chemosensitivity Assays | VI-30 · Effective Feb 2, 2026 · Commercial, Medicaid | 16 | Original policy ↗ |
| Infusion or Injection of Vitamins and/or Minerals | II-163 · Effective Dec 1, 2025 · Commercial, Medicaid | 6 | Original policy ↗ |
| Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | IV-133 · Effective Dec 1, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Interferential Current Stimulation | VII-66 · Effective Jun 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Intraosseous Basivertebral Nerve Ablation for Chronic Low Back Pain | IV-111 · Effective Sep 28, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Intravenous Anesthetics for Treatment of Chronic Pain and Psychiatric Disorders | II-271 · Effective Feb 2, 2026 · Commercial, Medicaid | 9 | Original policy ↗ |
| Investigative Indications for Medical Technologies Which Are Not Addressed by a Specific Medical Policy | XI-01 · Effective Sep 28, 2026 · Commercial, Medicaid | — | Original policy ↗ |
| Islet Cell Transplantation | IV-09 · Effective Sep 28, 2026 · Commercial, Medicaid | 8 | Original policy ↗ |
| Knee Arthroplasty (Knee Replacement) | IV-122 · Effective Sep 28, 2026 · Commercial, Medicaid | 9 | Original policy ↗ |
| Laser and Photodynamic Therapy for Onychomycosis | II-153 · Effective Aug 31, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Left Atrial Appendage Closure Devices | IV-169 · Effective Oct 27, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Liposuction | IV-82 · Effective Jul 27, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Low-Level and High-Power Laser Therapy | II-09 · Effective Mar 30, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Magnetic Esophageal Ring for Treatment of Gastroesophageal Reflux Disease (GERD) | IV-124 · Effective Apr 27, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Manipulation Under Anesthesia | II-116 · Effective Mar 30, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Mastopexy | IV-33 · Effective Sep 28, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Measurement of Serum Antibodies to Selected Biologic Agents | VI-55 · Effective Feb 2, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Mechanical Stretching Devices | VII-62 · Effective Dec 1, 2025 · Commercial, Medicaid | 30 | Original policy ↗ |
| Medical Marijuana (Cannabis) | II-221 · Effective Dec 1, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Medical Necessity Criteria for Medical Technologies Which Are Not Addressed by a Specific Medical Policy | XI-02 · Effective Sep 28, 2026 · Commercial, Medicaid | — | Original policy ↗ |
| Meniscal Allografts and Other Meniscal Implants | IV-114 · Effective Jun 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Microprocessor-Controlled Prostheses for the Lower Limb | VII-16 · Effective Sep 28, 2026 · Commercial, Medicaid | 33 | Original policy ↗ |
| Microwave Ablation of Solid Tumors | IV-04 · Effective Aug 31, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Mobile Cardiac Outpatient Telemetry | II-20 · Effective Mar 2, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Monitored Anesthesia Care with Selected Injections for Pain | II-261 · Effective Jun 1, 2026 · Commercial, Medicaid | 12 | Original policy ↗ |
| MRI-Guided High-Intensity Focused Ultrasound Ablation and MRI-Guided High-Intensity Directional Ultrasound Ablation | IV-119 · Effective May 4, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Myoelectric Prosthetic and Orthotic Components for the Upper Limb | VII-60 · Effective Sep 28, 2026 · Commercial, Medicaid | 18 | Original policy ↗ |
| Nasal Tissue Reduction | IV-172 · Effective Jul 27, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Nerve Fiber Density Measurement | II-177 · Effective Oct 27, 2025 · Commercial, Medicaid | 10 | Original policy ↗ |
| Nerve Graft with Prostatectomy | IV-147 · Effective Mar 2, 2026 · Commercial, Medicaid | 8 | Original policy ↗ |
| Neurofeedback | X-29 · Effective Mar 2, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Nonpharmacologic Treatment of Acne | II-33 · Effective Dec 1, 2025 · Commercial, Medicaid | 21 | Original policy ↗ |
| Nonpharmacologic Treatment of Rosacea | II-08 · Effective Dec 1, 2025 · Commercial, Medicaid | 29 | Original policy ↗ |
| Occipital Nerve Decompression for Treatment of Chronic Headache | IV-167 · Effective Mar 30, 2026 · Commercial, Medicaid | 11 | Original policy ↗ |
| Occipital Nerve Stimulation | II-140 · Effective Mar 30, 2026 · Commercial, Medicaid | 8 | Original policy ↗ |
| Optical Coherence Tomography of the Anterior Eye Segment | II-79 · Effective Mar 30, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Organ Transplantation | IV-128 · Effective Sep 28, 2026 · Commercial, Medicaid | 67 | Original policy ↗ |
