| Genetic Tests: Once per Lifetime | G-23002 · Effective Jan 1, 2024 · Medicaid · TX | — | Original policy ↗ |
| Genetic Tests: Once per Lifetime | G-23002 · Effective Jan 1, 2024 · Medicaid · TX | — | Original policy ↗ |
| Genetic Tests: Once per Lifetime | G-23002 · Effective Jan 1, 2024 · Medicaid · WV | — | Original policy ↗ |
| Global Surgical Package | G-06041 · Effective Apr 1, 2023 · Medicaid · DC | — | Original policy ↗ |
| Global Surgical Package | G-06041 · Effective Jan 30, 2023 · Medicaid · GA, MD, WA | — | Original policy ↗ |
| Global Surgical Package | G-06041 · Effective Jan 30, 2023 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Global Surgical Package | G-06041 · Effective Jan 30, 2023 · Medicaid · TX | — | Original policy ↗ |
| Global Surgical Package | G-06041 · Effective Jan 30, 2023 · Medicaid · TX | — | Original policy ↗ |
| Global Surgical Package | G-06041 · Effective Jan 30, 2023 · Medicaid · WV | — | Original policy ↗ |
| HealthChoice QRC | Medicaid · MD | — | Original policy ↗ |
| Hysterectomy | G-06164 · Effective Jul 17, 2024 · Medicaid · DC | — | Original policy ↗ |
| Hysterectomy | G-06164 · Effective Jul 17, 2024 · Medicaid · MD | — | Original policy ↗ |
| Hysterectomy | G-06164 · Effective Jul 14, 2024 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Hysterectomy | G-06164 · Effective Jul 17, 2024 · Medicaid · TX | — | Original policy ↗ |
| Hysterectomy | G-06164 · Effective Jul 17, 2024 · Medicaid · TX | — | Original policy ↗ |
| Hysterectomy | G-06164 · Effective Jul 17, 2024 · Medicaid · WV | — | Original policy ↗ |
| Inpatient admission and concurrent and retrospective review | Medicaid · MD | — | Original policy ↗ |
| Inpatient Readmissions | G-13001 · Effective Mar 25, 2025 · Medicaid · DC | — | Original policy ↗ |
| Inpatient Readmissions | G-13001 · Effective Mar 25, 2025 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Inpatient Readmissions | G-13001 · Effective Nov 1, 2025 · Medicaid · TX | — | Original policy ↗ |
| Inpatient Readmissions | Effective Jun 1, 2018 · Medicaid · TX | — | Original policy ↗ |
| Inpatient Readmissions | Effective Mar 4, 2020 · Medicaid · WV | — | Original policy ↗ |
| Locum Tenens Physicians/Fee-for-Time Compensation | G-06063 · Effective Aug 15, 2022 · Medicaid · TX | — | Original policy ↗ |
| Maternity Services | G-14001 · Effective Oct 23, 2025 · Medicaid · DC | — | Original policy ↗ |
| Maternity Services | G-14001 · Effective Oct 23, 2025 · Medicaid · MD | — | Original policy ↗ |
| Maternity Services | G-14001 · Effective Oct 23, 2025 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Maternity Services | G-14001 · Effective Oct 1, 2026 · Medicaid · TX | — | Original policy ↗ |
| Maternity Services | G-14001 · Effective Jul 7, 2023 · Medicaid · TX | — | Original policy ↗ |
| Maternity Services | G-14001 · Effective Oct 23, 2025 · Medicaid · WV | — | Original policy ↗ |
| Maximum Units Per Day | G-15003 · Effective Dec 2, 2025 · Medicaid · DC | — | Original policy ↗ |
| Maximum Units Per Day | G-15003 · Effective Dec 2, 2025 · Medicaid · MD | — | Original policy ↗ |
| Maximum Units Per Day | G-15003 · Effective Dec 2, 2025 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Maximum Units Per Day | G-15003 · Effective Dec 2, 2025 · Medicaid · TX | — | Original policy ↗ |
| Maximum Units Per Day | G-15003 · Effective Jun 16, 2021 · Medicaid · TX | — | Original policy ↗ |
| Maximum Units Per Day | G-15003 · Effective Dec 2, 2025 · Medicaid · WV | — | Original policy ↗ |
| May 2021 Clinical Utilization Management (UM) Guidelines | Medicaid · TX | — | Original policy ↗ |
| May 2023 Clinical Utilization Management Guidelines | Medicaid · TX | — | Original policy ↗ |
| May 2024 Clinical Utilization Management (UM) Guidelines | Medicaid · WV | — | Original policy ↗ |
| May 2024 Clinical Utilization Management Guidelines | Medicaid · MD | — | Original policy ↗ |
| May 2024 Clinical Utilization Management Guidelines | Medicaid · TX | — | Original policy ↗ |
| May 2025 Clinical Utilization Management Guidelines | Medicaid · MD | — | Original policy ↗ |
| May 2025 Clinical Utilization Management Guidelines | Medicaid · TX | — | Original policy ↗ |
| May 2025 Clinical Utilization Management Guidelines | Medicaid · WV | — | Original policy ↗ |
| Medicaid provider manual | Medicaid · WV | 178 | Original policy ↗ |
| Medicaid/CHIP Provider Quick Reference Guide | Medicaid · TX | 2 | Original policy ↗ |
| Medical Recalls | G-06111 · Effective May 22, 2024 · Medicaid · DC | — | Original policy ↗ |
| Medical Recalls | G-06111 · Effective Nov 1, 2018 · Medicaid · MD | — | Original policy ↗ |
| Medical Recalls | G-06111 · Effective May 22, 2024 · AZ, IA, NJ, SC, TN, TX, WA | — | Original policy ↗ |
| Medical Recalls | G-06111 · Effective Feb 10, 2022 · Medicaid · TX | — | Original policy ↗ |
| Medical Recalls | G-06111 · Effective Nov 1, 2018 · Medicaid · TX | — | Original policy ↗ |
