| Botulinum Toxin | RX501.019 · Effective Jan 1, 2026 · Commercial, Medicaid | 28 | Original policy ↗ |
| Brolucizumab-dbll | OTH903.043 · Effective Sep 15, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Bronchial Thermoplasty | SUR706.014 · Effective Dec 15, 2025 · Commercial, Medicaid | 2 | Original policy ↗ |
| Bronchial Valves | SUR706.015 · Commercial, Medicaid | 4 | Original policy ↗ |
| Burosumab-twza | RX502.058 · Commercial, Medicaid | 1 | Original policy ↗ |
| Canakinumab | RX501.119 · Effective Apr 15, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Cardiac Applications of Positron Emission Tomography Scanning | RAD605.001 · Commercial, Medicaid | 13 | Original policy ↗ |
| Cardiac Contractility Modulation Device | MED202.068 · Commercial, Medicaid | 32 | Original policy ↗ |
| Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting | MED202.058 · Effective Jan 1, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Cardiac Rehabilitation in the Outpatient Setting | THE803.023 · Effective Sep 15, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Category III Current Procedural Terminology (CPT®) Codes | ADM1001.035 · Effective Jul 1, 2026 · Commercial, Medicaid | 517 | Original policy ↗ |
| Cerliponase alfa | RX501.092 · Commercial, Medicaid | 1 | Original policy ↗ |
| Certolizumab Pegol | RX501.111 · Commercial, Medicaid | 1 | Original policy ↗ |
| Chelation Therapy for Off-Label Uses | THE801.008 · Commercial, Medicaid | 9 | Original policy ↗ |
| Chemical Peels | SUR716.018 · Effective Sep 1, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Children's Wellness Guidelines | 350139.0925 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Children's Wellness Guidelines (Spanish) | 362079.0925 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Chromoendoscopy as an Adjunct to Colonoscopy | MED201.022 · Commercial, Medicaid | 2 | Original policy ↗ |
| Clinical Trial Treatment or Therapy | ADM1001.027 · Commercial, Medicaid | 13 | Original policy ↗ |
| Closure Devices for Patent Foramen Ovale and Atrial Septal Defects | SUR707.024 · Commercial, Medicaid | 2 | Original policy ↗ |
| Cochlear Implant | SUR714.004 · Effective Jan 1, 2026 · Commercial, Medicaid | 20 | Original policy ↗ |
| Cognitive Rehabilitation | THE803.019 · Effective Jan 1, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Collection and Storage of Umbilical Cord Blood Stem Cells | SUR703.058 · Commercial, Medicaid | 5 | Original policy ↗ |
| Composite Tissue Allotransplantation of the Hand and Face | SUR703.052 · Commercial, Medicaid | 1 | Original policy ↗ |
| Compression Pumps for Treatment of Lymphedema and Venous Ulcers | MED202.060 · Commercial, Medicaid | 33 | Original policy ↗ |
| Computed Tomography to Detect Coronary Artery Calcification | RAD604.009 · Commercial, Medicaid | 10 | Original policy ↗ |
| Computer-Assisted Navigation for Orthopedic Procedures | SUR705.023 · Effective Sep 1, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Confocal Laser Endomicroscopy (CLE) | MED201.038 · Commercial, Medicaid | 4 | Original policy ↗ |
| Continuous Passive Motion in the Home Setting | DME101.023 · Commercial, Medicaid | 3 | Original policy ↗ |
| Corneal Collagen Cross-Linking | OTH903.028 · Commercial, Medicaid | 5 | Original policy ↗ |
| Corneal Hysteresis | OTH903.031 · Commercial, Medicaid | 1 | Original policy ↗ |
| Cosmetic and Reconstructive Procedures | SUR716.001 · Commercial, Medicaid | 62 | Original policy ↗ |
| Cranial Electrotherapy Stimulation and Auricular Electrostimulation | SUR702.019 · Effective Sep 1, 2026 · Commercial, Medicaid | 11 | Original policy ↗ |
| Crizanlizumab-tmca | RX501.126 · Commercial, Medicaid | 1 | Original policy ↗ |
| Crovalimab-akkz | RX501.176 · Commercial, Medicaid | 1 | Original policy ↗ |
| Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone | SUR701.018 · Effective Jan 1, 2026 · Commercial, Medicaid | 11 | Original policy ↗ |
| Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis | SUR706.020 · Effective Jun 15, 2025 · Commercial, Medicaid | 6 | Original policy ↗ |
| Cryosurgical Ablation of Primary or Metastatic Liver Tumors | SUR701.032 · Commercial, Medicaid | 5 | Original policy ↗ |
| Custodial Care | ADM1001.014 · Commercial, Medicaid | 13 | Original policy ↗ |
| Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) | SUR712.037 · Effective Nov 15, 2025 · Commercial, Medicaid | 3 | Original policy ↗ |
| Deep Brain Stimulation | SUR712.025 · Effective Sep 15, 2026 · Commercial, Medicaid | 17 | Original policy ↗ |
| Delandistrogene moxeparvovec-rokl | RX501.163 · Effective Jan 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Denosumab and Biosimilars for Non-Oncologic Indications | RX501.140 · Commercial, Medicaid | 14 | Original policy ↗ |
| Depemokimab-ulaa | RX501.192 · Effective Sep 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Dermatologic Applications of Photodynamic Therapy | THE801.027 · Commercial, Medicaid | 6 | Original policy ↗ |
| Device Therapies for Gastroesophageal Reflux Disease (GERD) | MED201.016 · Effective Jan 1, 2026 · Commercial, Medicaid | 10 | Original policy ↗ |
| Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis | MED202.064 · Commercial, Medicaid | 6 | Original policy ↗ |
| Diagnosis of Obstructive Sleep Apnea Syndrome | MED204.005 · Effective Jan 1, 2026 · Commercial, Medicaid | 14 | Original policy ↗ |
| Digital Health Technologies for Attention Deficit/Hyperactivity Disorder | PSY301.022 · Commercial, Medicaid | 5 | Original policy ↗ |
| Digital Health Technologies: Diagnostic Applications | PSY301.024 · Effective Dec 15, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
