| Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR) | SUR710.022 · Commercial, Medicaid | 4 | Original policy ↗ |
| Photodynamic Therapy for Choroidal Neovascularization | OTH903.015 · Effective Dec 15, 2025 · Commercial, Medicaid | 9 | Original policy ↗ |
| Phototherapeutic Keratectomy | SUR713.023 · Commercial, Medicaid | 5 | Original policy ↗ |
| Phrenic Nerve Stimulation for Central Sleep Apnea | SUR701.042 · Commercial, Medicaid | 13 | Original policy ↗ |
| Physical Therapy (PT) and Occupational Therapy (OT) Services | THE803.010 · Commercial, Medicaid | 69 | Original policy ↗ |
| Plugs for Anal Fistula Repair | SUR709.032 · Commercial, Medicaid | 1 | Original policy ↗ |
| Polysomnography for Non-Respiratory Sleep Disorders | MED201.049 · Commercial, Medicaid | 6 | Original policy ↗ |
| Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis | MED202.073 · Commercial, Medicaid | 16 | Original policy ↗ |
| Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities | DME103.008 · Effective Sep 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Pozelimab-bbfg | RX501.182 · Commercial, Medicaid | 1 | Original policy ↗ |
| Preventive Care Guidelines | 360384.0126 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia | SUR703.027 · Commercial, Medicaid | 7 | Original policy ↗ |
| Prolotherapy | MED201.013 · Effective Jun 15, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Prostate Artery Embolization for Benign Prostatic Hyperplasia | SUR710.027 · Commercial, Medicaid | 1 | Original policy ↗ |
| Prostatic Urethral Lift | SUR710.023 · Effective Oct 15, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Provider ID Policy | N005.2 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Provider in Training Policy | N006.5 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Provider Network Participation Policy | N007.1 · Commercial, Medicaid · MT | — | Original policy ↗ |
| Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder, Cognitive Impairment, or Autism Spectrum Disorder | MED205.040 · Commercial, Medicaid | 6 | Original policy ↗ |
| Quantitative Sensory Testing | MED205.030 · Commercial, Medicaid | 6 | Original policy ↗ |
| Radioembolization for Primary and Metastatic Tumors of the Liver | RAD601.047 · Commercial, Medicaid | 7 | Original policy ↗ |
| Radiofrequency Ablation (RFA) of Primary or Metastatic Liver Tumors | SUR709.029 · Effective Jan 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors | SUR701.021 · Effective Dec 1, 2025 · Commercial, Medicaid | 12 | Original policy ↗ |
| Radiofrequency Energy Therapy for Stress Urinary Incontinence | SUR710.021 · Commercial, Medicaid | 3 | Original policy ↗ |
| Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction | SUR706.001 · Effective Sep 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Ravulizumab-cwvz | RX501.107 · Commercial, Medicaid | 1 | Original policy ↗ |
| Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions | RX501.034 · Effective Apr 15, 2026 · Commercial, Medicaid | 6 | Original policy ↗ |
| Reconstructive Breast Surgery | SUR716.011 · Commercial, Medicaid | 38 | Original policy ↗ |
| Reconstructive Breast Surgery/Management of Breast Implants | SUR716.009 · Commercial, Medicaid | 10 | Original policy ↗ |
| Reduction Mammaplasty for Breast-Related Symptoms | SUR716.012 · Commercial, Medicaid | 1 | Original policy ↗ |
| Remdesivir | RX501.130 · Commercial, Medicaid | 1 | Original policy ↗ |
| Remote Electrical Neuromodulation for Migraines | SUR701.046 · Commercial, Medicaid | 2 | Original policy ↗ |
| Renal Denervation for Uncontrolled Hypertension | SUR701.030 · Effective Oct 15, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Reproductive Techniques and Immunotherapy for Recurrent Fetal Loss | OB402.023 · Commercial, Medicaid | 49 | Original policy ↗ |
| Reslizumab | RX501.083 · Commercial, Medicaid | 1 | Original policy ↗ |
| Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy | SUR712.039 · Effective Dec 1, 2025 · Commercial, Medicaid | 18 | Original policy ↗ |
| Revakinagene taroretcel-lwey | RX501.185 · Commercial, Medicaid | 1 | Original policy ↗ |
| Rhinomanometry, Acoustic Rhinometry, Optical Rhinometry and Acoustic Pharyngometry | MED204.004 · Commercial, Medicaid | 3 | Original policy ↗ |
| Risankizumab-rzaa | RX501.147 · Commercial, Medicaid | 1 | Original policy ↗ |
| Rituximab and Biosimilars for Non-Oncologic Indications | RX502.030 · Effective Jan 1, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Romiplostim | RX501.157 · Commercial, Medicaid | 2 | Original policy ↗ |
| Romosozumab-aqqg | RX501.159 · Commercial, Medicaid | 1 | Original policy ↗ |
| Rozanolixixumab-noli | RX501.161 · Effective Dec 15, 2025 · Commercial, Medicaid | 1 | Original policy ↗ |
| Sacral Nerve Neuromodulation/Stimulation | SUR710.018 · Commercial, Medicaid | 21 | Original policy ↗ |
| Sacroiliac Joint Injections | SUR705.043 · Effective Jan 1, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| SARS-CoV-2 (COVID-19) Antibody Testing | MED207.162 · Commercial, Medicaid | 8 | Original policy ↗ |
| Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy | SUR717.015 · Commercial, Medicaid | 5 | Original policy ↗ |
| Scleral Shell | DME104.003 · Commercial, Medicaid | 3 | Original policy ↗ |
| Seat Lift Mechanisms and Patient Lifts | DME101.034 · Commercial, Medicaid | 16 | Original policy ↗ |
| Secukinumab | RX501.169 · Effective Jun 15, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
