| Injectable Clostridial Collagenase for Fibroproliferative Disorders | RX501.073 · Commercial, Medicaid | 9 | Original policy ↗ |
| Inside the U.S. Food and Drug Administration (FDA) | ADM1001.028 · Commercial, Medicaid | 4 | Original policy ↗ |
| Insulin Potentiation Therapy | THE801.035 · Commercial, Medicaid | 1 | Original policy ↗ |
| Interferential Current Stimulation | MED201.041 · Commercial, Medicaid | 7 | Original policy ↗ |
| Intermittent Intravenous Insulin Therapy | MED201.028 · Commercial, Medicaid | 1 | Original policy ↗ |
| Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | SUR712.029 · Effective Nov 1, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Interspinous Fixation (Fusion) Devices | SUR712.040 · Effective Nov 15, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Interventions for Progressive Scoliosis | SUR705.046 · Effective Sep 1, 2026 · Commercial, Medicaid | 37 | Original policy ↗ |
| Intracellular Micronutrient Analysis | MED207.088 · Commercial, Medicaid | 7 | Original policy ↗ |
| Intraocular Lens (IOLs) and Implantable Miniature Telescope (IMT) | SUR713.025 · Commercial, Medicaid | 13 | Original policy ↗ |
| Intraoperative Neurophysiologic Monitoring (IONM) | MED205.011 · Commercial, Medicaid | 23 | Original policy ↗ |
| Intraosseous Radiofrequency Nerve Ablation of the Basivertebral Nerve for the Treatment of Low Back Pain | SUR702.020 · Commercial, Medicaid | 3 | Original policy ↗ |
| Intraurethral Valve Drainage Device for Impaired Detrusor Contractility | DME102.009 · Commercial, Medicaid | 4 | Original policy ↗ |
| Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders | SUR702.016 · Effective Jan 1, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease | MED207.104 · Commercial, Medicaid | 12 | Original policy ↗ |
| Intravitreal, Punctum, and Intracameral Implants | OTH903.024 · Commercial, Medicaid | 12 | Original policy ↗ |
| Irreversible Electroporation (IRE) | SUR701.048 · Commercial, Medicaid | 4 | Original policy ↗ |
| Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes | SUR703.057 · Commercial, Medicaid | 10 | Original policy ↗ |
| Isolated Small Bowel Transplant | SUR703.014 · Commercial, Medicaid | 9 | Original policy ↗ |
| Keratoprosthesis | OTH903.030 · Commercial, Medicaid | 3 | Original policy ↗ |
| Kidney Transplant | SUR703.007 · Commercial, Medicaid | 13 | Original policy ↗ |
| KidneyIntelX and KidneyIntelX.dkd Testing | MED207.163 · Commercial, Medicaid | 2 | Original policy ↗ |
| Laboratory Testing Investigational Services | MED207.164 · Effective Apr 1, 2026 · Commercial, Medicaid | 28 | Original policy ↗ |
| Lanreotide | RX501.155 · Commercial, Medicaid | 2 | Original policy ↗ |
| Laparoscopic, Percutaneous and Transcervical Techniques for Uterine Fibroid Myolysis | SUR701.033 · Effective Jan 1, 2026 · Commercial, Medicaid | 8 | Original policy ↗ |
| Laser Interstitial Tumor Therapy (LITT) | SUR701.031 · Commercial, Medicaid | 13 | Original policy ↗ |
| Leadless Cardiac Pacemakers | SUR707.030 · Effective Nov 1, 2025 · Commercial, Medicaid | 17 | Original policy ↗ |
| Lecanemab-irmb | RX501.152 · Commercial, Medicaid | 1 | Original policy ↗ |
| Lien Claim Payment for Non-Participating Providers | N001.1 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Liposuction for Lipedema and Lymphedema | SUR708.003 · Effective Jan 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Liver Transplant and Combined Liver-Kidney Transplant | SUR703.008 · Commercial, Medicaid | 24 | Original policy ↗ |
| Locum Tenens Provider Policy | Commercial · MT | — | Original policy ↗ |
| Long-Acting Injectable Antiretroviral Agents for Treatment of HIV | RX501.145 · Effective Apr 1, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Telemetry, Implantable Cardiac Rhythm Event Monitors, and Intracardiac Ischemia Detection Systems) | MED202.003 · Effective Jan 1, 2026 · Commercial, Medicaid | 20 | Original policy ↗ |
| Low-Level Laser Therapy | MED201.045 · Commercial, Medicaid | 3 | Original policy ↗ |
| Lower Esophageal Magnetic Sphincter Augmentation | SUR709.036 · Commercial, Medicaid | 2 | Original policy ↗ |
| Lower-Limb Prosthetics, Including Microprocessor-Controlled Prosthetics | DME104.012 · Commercial, Medicaid | 222 | Original policy ↗ |
| Lumasiran | RX501.133 · Effective Sep 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Lumbar Spinal Fusion | SUR712.036 · Effective Jan 1, 2026 · Commercial, Medicaid | 37 | Original policy ↗ |
| Lung and Lobar Lung Transplant | SUR703.010 · Commercial, Medicaid | 10 | Original policy ↗ |
| Lysis of Epidural Adhesions | SUR712.024 · Commercial, Medicaid | 5 | Original policy ↗ |
| Magnetic Resonance-Guided Focused Ultrasound | SUR701.022 · Commercial, Medicaid | 6 | Original policy ↗ |
| Management of Hereditary Angioedema (HAE) with C1 Esterase Inhibitor, Human and Ecallantide | RX504.013 · Effective Jan 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Manipulation Under Anesthesia | THE803.016 · Effective Sep 15, 2026 · Commercial, Medicaid | 9 | Original policy ↗ |
| Mastopexy | SUR716.010 · Commercial, Medicaid | 1 | Original policy ↗ |
| Measurement of Serum Antibodies to Selected Biologic Agents | MED207.153 · Effective Jan 1, 2026 · Commercial, Medicaid | 6 | Original policy ↗ |
| Medical Management of Sleep Related Breathing Disorders | MED204.006 · Effective May 15, 2026 · Commercial, Medicaid | 37 | Original policy ↗ |
| Medical Policies Moving to MCG Guidelines | ADM1001.036 · Commercial, Medicaid | 303 | Original policy ↗ |
| Medicare Advantage Annual Wellness Visit Form | Medicaid · MT | 4 | Original policy ↗ |
| Medicare Advantage Annual Wellness Visit Guide | Medicaid · MT | 8 | Original policy ↗ |
