| Duplicate or Subsequent Services on the Same Date of Service | G-06032 · Effective May 22, 2024 · Medicaid · DC | — | Original policy ↗ |
| Duplicate or Subsequent Services on the Same Date of Service | G-06032 · Effective May 22, 2024 · Medicaid · MD | — | Original policy ↗ |
| Duplicate or Subsequent Services on the Same Date of Service | G-06032 · Effective May 22, 2024 · AZ, IA, SC, WA | — | Original policy ↗ |
| Duplicate or Subsequent Services on the Same Date of Service | G-06032 · Effective May 22, 2024 · Medicaid · TX | — | Original policy ↗ |
| Duplicate or Subsequent Services on the Same Date of Service | G-06032 · Effective Apr 11, 2022 · Medicaid · TX | — | Original policy ↗ |
| Durable Medical Equipment (Rent to Purchase) | G-06052 · Effective Oct 6, 2025 · Medicaid · DC | — | Original policy ↗ |
| Durable Medical Equipment (Rent to Purchase) | G-06052 · Effective Oct 6, 2025 · Medicaid · MD | — | Original policy ↗ |
| Durable Medical Equipment (Rent to Purchase) | G-06052 · Effective Oct 6, 2025 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Durable Medical Equipment (Rent to Purchase) | G-06052 · Effective Oct 6, 2025 · Medicaid · TX | — | Original policy ↗ |
| Durable Medical Equipment (Rent to Purchase) | G-06052 · Effective Jun 13, 2023 · Medicaid · TX | — | Original policy ↗ |
| Durable Medical Equipment Rent to Purchase | G-06052 · Effective Oct 6, 2025 · Medicaid · WV | — | Original policy ↗ |
| Early and Periodic Screening Diagnostic Treatment (EPSDT) | G-06049 · Effective Jul 21, 2025 · Medicaid · DC | — | Original policy ↗ |
| Early and Periodic Screening Diagnostic Treatment (EPSDT) | G-06049 · Effective Jul 21, 2025 · Medicaid · MD | — | Original policy ↗ |
| Early and Periodic Screening Diagnostic Treatment (EPSDT) | G-06049 · Effective Jul 21, 2025 · Medicaid · TX | — | Original policy ↗ |
| Early and Periodic Screening Diagnostic Treatment (EPSDT) | G-06049 · Effective Jul 21, 2025 · Medicaid · WV | — | Original policy ↗ |
| Eligible Billed Charges | G-06001 · Effective Nov 4, 2024 · Medicaid · GA, MD, WA | — | Original policy ↗ |
| Eligible Billed Charges | G-06001 · Effective Nov 4, 2024 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Eligible Billed Charges | G-06001 · Effective Nov 4, 2024 · Medicaid · TX | — | Original policy ↗ |
| Eligible Billed Charges | G-06001 · Effective May 16, 2022 · Medicaid · TX | — | Original policy ↗ |
| Eligible Billed Charges | G-06001 · Effective May 16, 2022 · Medicaid · WV | — | Original policy ↗ |
| Emergency Department Leveling of Evaluation and Management Services | G-19002 · Effective Jan 16, 2024 · Medicaid · DC | — | Original policy ↗ |
| Emergency Department Leveling of Evaluation and Management Services | G-19002 · Effective Apr 1, 2026 · Medicaid · TX | — | Original policy ↗ |
| Emergency Department Leveling of Evaluation and Management Services | G-19002 · Effective Jan 16, 2024 · Medicaid · WV | — | Original policy ↗ |
| Emergency Department: Level of E&M Services | Medicaid · MD | 10 | Original policy ↗ |
| Emergency Department: Leveling of Evaluation and Management Services | G-19002 · Effective Jan 1, 2024 · SC | — | Original policy ↗ |
| Emergency Services: Non-Participating Providers and Facilities | G-06092 · Effective Sep 6, 2024 · Medicaid · DC | — | Original policy ↗ |
| Emergency Services: Non-Participating Providers and Facilities | G-06092 · Effective Sep 6, 2025 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Emergency Services: Non-Participating Providers and Facilities | G-06092 · Effective Sep 6, 2024 · Medicaid · WV | — | Original policy ↗ |
| Facility Take-Home DME and Medical Supplies | G-06081 · Effective May 22, 2024 · Medicaid · DC | — | Original policy ↗ |
| Facility Take-Home DME and Medical Supplies | G-06081 · Effective May 22, 2024 · Medicaid · MD | — | Original policy ↗ |
| Facility Take-Home DME and Medical Supplies | G-06081 · Effective May 22, 2024 · AZ, IA, NJ, NM, SC, TN, TX, WA | — | Original policy ↗ |
| Facility Take-Home DME and Medical Supplies | G-06081 · Effective May 22, 2024 · Medicaid · TX | — | Original policy ↗ |
| Facility Take-Home DME and Medical Supplies | G-06081 · Effective May 22, 2024 · Medicaid · TX | — | Original policy ↗ |
| Facility Take-Home DME and Medical Supplies | G-06081 · Effective May 22, 2024 · Medicaid · WV | — | Original policy ↗ |
| February 2022 Clinical Utilization Management (UM) Guidelines | Effective Mar 24, 2022 · Medicaid · MD | — | Original policy ↗ |
| February 2022 Clinical Utilization Management (UM) Guidelines | Medicaid · TX | — | Original policy ↗ |
| February 2023 Clinical Utilization Management Guidelines | Medicaid · TX | — | Original policy ↗ |
| February 2024 Clinical Utilization Management (UM) Guidelines | Medicaid · WV | — | Original policy ↗ |
| February 2024 Clinical Utilization Management Criteria | Medicaid · MD | — | Original policy ↗ |
| February 2024 Clinical Utilization Management Guidelines | Medicaid · TX | — | Original policy ↗ |
| February 2025 Clinical Utilization Management Guidelines | Medicaid · MD | — | Original policy ↗ |
| February 2025 Clinical Utilization Management Guidelines | Medicaid · TX | — | Original policy ↗ |
| February 2025 Clinical Utilization Management Guidelines | Medicaid · WV | — | Original policy ↗ |
| February 2026 Clinical Utilization Management Guidelines | Medicaid · MD | — | Original policy ↗ |
| February 2026 Clinical Utilization Management Guidelines | Medicaid · TX | — | Original policy ↗ |
| February 2026 Clinical Utilization Management Guidelines | Medicaid · WV | — | Original policy ↗ |
| GBD Claims with Charge Discrepancies | Medicaid · WA | — | Original policy ↗ |
| Genetic Tests: Once per Lifetime | G-23002 · Effective Oct 23, 2025 · Medicaid · DC | — | Original policy ↗ |
| Genetic Tests: Once per Lifetime | G-23002 · Effective Jul 1, 2026 · Medicaid · MD | — | Original policy ↗ |
| Genetic Tests: Once per Lifetime | G-23002 · Effective Jul 1, 2026 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
