| Meniscal Allografts and Other Meniscal Implants | SUR705.034 · Effective Jul 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Mepolizumab | RX501.080 · Commercial, Medicaid | 4 | Original policy ↗ |
| Microwave Tumor Ablation | SUR701.038 · Effective Dec 15, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine | RAD601.041 · Effective Sep 1, 2026 · Commercial, Medicaid | 13 | Original policy ↗ |
| Minimally Invasive Fixation/Fusion of the Sacroiliac Joint | SUR705.033 · Effective Nov 1, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Mirikizumab-mrkz | RX501.168 · Commercial, Medicaid | 1 | Original policy ↗ |
| Myocardial Strain Imaging | RAD601.069 · Commercial, Medicaid | 3 | Original policy ↗ |
| Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure | RAD604.012 · Commercial, Medicaid | 4 | Original policy ↗ |
| Myoelectric Prosthetic and Orthotic Components for the Upper Limb | DME104.001 · Effective Jun 15, 2026 · Commercial, Medicaid | 48 | Original policy ↗ |
| Narsoplimab-wuug | RX501.193 · Commercial, Medicaid | 1 | Original policy ↗ |
| Natalizumab and Associated Biosimilar(s) | RX501.059 · Effective May 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Negative Pressure Wound Therapy in the Outpatient Setting | DME101.036 · Commercial, Medicaid | 13 | Original policy ↗ |
| Nerve Graft with Radical Prostatectomy | SUR710.019 · Commercial, Medicaid | 9 | Original policy ↗ |
| Network Management | Commercial, Medicaid · MT | — | Original policy ↗ |
| Neuralgia Inducing Cavitational Osteonecrosis (NICO) | SUR705.028 · Commercial, Medicaid | 12 | Original policy ↗ |
| Nipocalimab-aahu | RX501.188 · Commercial, Medicaid | 1 | Original policy ↗ |
| Non-Invasive Measurement of Central Blood Pressure (cBP) | MED202.070 · Effective Sep 15, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Noncontact Normothermic Wound Therapy (NNWT) | DME101.050 · Commercial, Medicaid | 3 | Original policy ↗ |
| Noncontact Ultrasound Treatment for Wounds | DME101.044 · Commercial, Medicaid | 1 | Original policy ↗ |
| Nonpharmacologic Treatment of Rosacea | THE801.030 · Effective May 1, 2026 · Commercial, Medicaid | 19 | Original policy ↗ |
| Nonwearable Automatic External Defibrillators | DME101.021 · Commercial, Medicaid | 1 | Original policy ↗ |
| Nusinersen | RX501.086 · Effective Jan 1, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Nutritional Support | MED201.011 · Commercial, Medicaid | 66 | Original policy ↗ |
| Obinutuzumab | RX501.187 · Commercial, Medicaid | 1 | Original policy ↗ |
| Occipital Nerve Stimulation | SUR712.033 · Commercial, Medicaid | 19 | Original policy ↗ |
| Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsq | RX501.085 · Commercial, Medicaid | 2 | Original policy ↗ |
| Octreotide acetate | RX501.156 · Commercial, Medicaid | 2 | Original policy ↗ |
| Omalizumab | RX501.058 · Commercial, Medicaid | 1 | Original policy ↗ |
| Onasemnogene abeparvovec-brve | RX501.186 · Effective Jul 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Onasemnogene abeparvovec-xioi | RX501.104 · Effective Jan 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus | THE801.029 · Commercial, Medicaid | 5 | Original policy ↗ |
| Oncology Medications | RX502.061 · Effective Jul 1, 2026 · Commercial, Medicaid | 175 | Original policy ↗ |
| Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma | OTH903.022 · Effective Jan 1, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Optical Coherence Tomography of the Anterior Eye Segment | OTH903.021 · Commercial, Medicaid | 1 | Original policy ↗ |
| Organ and Tissue Transplantation (General Donor and Recipient Information) | SUR703.001 · Effective Jan 1, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Orthognathic Surgery | SUR705.030 · Commercial, Medicaid | 32 | Original policy ↗ |
| Orthopedic Applications of Platelet-Rich Plasma | RX501.101 · Effective Sep 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow) | SUR703.051 · Commercial, Medicaid | 11 | Original policy ↗ |
| Outpatient Pulmonary Rehabilitation | THE803.025 · Effective Sep 15, 2026 · Commercial, Medicaid | 12 | Original policy ↗ |
| Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty | SUR705.037 · Effective Sep 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Pegloticase | RX501.120 · Commercial, Medicaid | 1 | Original policy ↗ |
| Pelvic Floor Stimulation as a Treatment of Urinary or Fecal Incontinence | DME101.037 · Commercial, Medicaid | 5 | Original policy ↗ |
| Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome | MED201.055 · Commercial, Medicaid | 2 | Original policy ↗ |
| Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy | MED205.032 · Effective Oct 15, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty | SUR712.023 · Commercial, Medicaid | 2 | Original policy ↗ |
| Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation | SUR701.009 · Effective Jul 15, 2025 · Commercial, Medicaid | 2 | Original policy ↗ |
| Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease | SUR707.034 · Effective Jan 1, 2026 · Commercial, Medicaid | 78 | Original policy ↗ |
| Perinatal Wellness Guidelines | 351383.0925 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Perinatal Wellness Guidelines (Spanish) | 362059.0925 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Peripheral Subcutaneous Field Stimulation | MED205.036 · Commercial, Medicaid | 1 | Original policy ↗ |
