| Hematopoietic Stem Cell Transplantation for Hematologic Disorders | Commercial, Medicaid | 23 | Original policy ↗ |
| Hematopoietic Stem Cell Transplantation for Non - Cancerous Diseases | 454 · Commercial | 24 | Original policy ↗ |
| Hematopoietic Stem Cell Transplantation for Solid Tumors | 457 · Commercial, Medicaid | 21 | Original policy ↗ |
| Hemgenix (etranacogene dezaparvovec-drlb) | 429 · Commercial, Medicaid | 3 | Original policy ↗ |
| High Dollar Pharmacy | Commercial | — | Original policy ↗ |
| High Dollar Pharmacy | Medicaid · FL, IA, ID, MA, MI, NM, NY, OH, SC, TX, WA, WI | — | Original policy ↗ |
| High Level Evaluation and Management with Preventive Medicine | Commercial | 10 | Original policy ↗ |
| High Level Evaluation and Management with Preventive Medicine | Medicaid · AZ, CA, FL, IA, ID, MA, MI, NE, NM, NY, OH, SC, TX, UT, WA, WI | 10 | Original policy ↗ |
| High-Level Evaluation and Management with Preventive Medicine | | 10 | Original policy ↗ |
| Hospice | Effective Feb 19, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Hospice | Effective Feb 19, 2025 · Medicaid · AZ, FL, IA, ID, MI, NE, OH, SC, TX, UT, WI | — | Original policy ↗ |
| Hospice Value Code 61 | Effective Aug 4, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Hospice Value Code 61 | Effective Aug 4, 2025 · Medicaid · AZ, CA, FL, IA, ID, MA, MI, NE, NM, NV, OH, SC, TX, WI | — | Original policy ↗ |
| Hospital Readmission Review | Commercial, Medicaid | — | Original policy ↗ |
| Hospital Readmission Review Policy | Medicaid · TX | — | Original policy ↗ |
| Hospital Routine Supplies Services | Commercial | — | Original policy ↗ |
| Hospital Routine Supplies Services | Medicaid · AZ, CA, FL, IA, ID, MA, MI, NE, NM, NY, OH, SC, TX, UT, WA, WI | — | Original policy ↗ |
| Hyaluronic Acid Injections | Medicaid | 13 | Original policy ↗ |
| Hydrolyzed Enteral Formula Diagnosis | Commercial | 30 | Original policy ↗ |
| Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (OSA) | 363 · Effective Apr 8, 2026 · Commercial, Medicaid | 9 | Original policy ↗ |
| ICD-10 First Listed Diagnosis Coding Policy | Commercial, Medicaid | — | Original policy ↗ |
| ICD-10 First Listed Diagnosis Coding Policy | | — | Original policy ↗ |
| ICD-10 Specificity | Commercial, Medicaid | 2 | Original policy ↗ |
| ICD-10 Specificity | | 1 | Original policy ↗ |
| Image Guided Radiation Therapy | Effective Aug 4, 2025 · Commercial, Medicaid | 5 | Original policy ↗ |
| Image Guided Radiation Therapy | Effective Aug 4, 2025 · Medicaid · AZ, CA, FL, IA, ID, IL, MA, MI, NE, NM, NV, NY, OH, SC, TX, WI | 5 | Original policy ↗ |
| Image-Guided Bronchoscopy Evaluation of Pulmonary Lesions | Commercial, Medicaid | 4 | Original policy ↗ |
| Implantable Intrathecal Pain Pump | Commercial, Medicaid | 21 | Original policy ↗ |
| Implantable Neurostimulator for Central Sleep Apnea | 340 · Commercial, Medicaid | 13 | Original policy ↗ |
| Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain | 444 · Commercial, Medicaid | 28 | Original policy ↗ |
| Implantable Shock Absorbers for Knee Osteoarthritis | Commercial | 2 | Original policy ↗ |
| Implanted Tibial Nerve Stimulation for Urinary Incontinence | Commercial, Medicaid | 8 | Original policy ↗ |
| Implanted Tibial Nerve Stimulation for Urinary Incontinence MEDICARE | | 8 | Original policy ↗ |
| Incarceration Diagnosis Code | Commercial, Medicaid | — | Original policy ↗ |
| Incarceration Diagnosis Code | Medicaid · IA, ID, MA, MI, SC, TX, UT, WI | — | Original policy ↗ |
| Infertility Evaluation and Treatments | 476 · Commercial, Medicaid | 162 | Original policy ↗ |
| Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure | Commercial, Medicaid | 4 | Original policy ↗ |
| Injections and Nerve Blocks for Neck and Back Pain | 468 · Effective Apr 8, 2026 · Commercial, Medicaid | 25 | Original policy ↗ |
| Inpatient services billed on Outpatient bill types | Medicaid | 1 | Original policy ↗ |
| Inpatient services billed on Outpatient bill types | Medicaid · AZ, CA, IA, ID, MI, NE, NM, NY, OH, TX, UT, WI | 1 | Original policy ↗ |
| Interspinous Decompression and Interlaminar Stabilization Devices for Spinal Stenosis | Commercial, Medicaid | 5 | Original policy ↗ |
| Interspinous Process Fixation Devices for Spinal Fusion | Commercial, Medicaid | 1 | Original policy ↗ |
| Intervertebral Stabilization Devices | Commercial, Medicaid | 1 | Original policy ↗ |
| Intradialytic Parenteral Nutrition and Intraperitoneal Parenteral Nutrition | 421 · Commercial | 42 | Original policy ↗ |
| Intraoperative Neurophysiologic Monitoring (IONM) | 481 · Effective Apr 8, 2026 · Commercial, Medicaid | 3 | Original policy ↗ |
| Itvisma (onasemnogene abeparvovec) | Commercial, Medicaid | 3 | Original policy ↗ |
| Itvisma (onasemnogene abeparvovec) MEDICARE | | 3 | Original policy ↗ |
| Kebilidi (eladocagene exuparvovec) | Commercial, Medicaid | 3 | Original policy ↗ |
| Ketogenic Diet for Treatment of Intractable Seizures | Commercial, Medicaid | 3 | Original policy ↗ |
| Kidney Transplantation | 045 · Commercial | 15 | Original policy ↗ |
