Presbyterian Health Plan, Inc. Medical Policy Manual
The Medical Policy Manual is updated on a routine basis. Please click on the link below for a current summary of updates.
All services provided must be medically necessary as determined by the member's practitioner or provider in consultation with PHP.
Behavioral Health Medical Necessity Criteria (Medicare/Commercial) Care Guidelines Evolent (formerly NIA) Medical Necessity Criteria
- Optum 2024 Solid Organ Transplantation Clinical Guideline
- Optum 2024 Hematopoietic Stem Cell Transplantation Clinical Guideline
Stanson Health Resources and Criteria
A
- Acupuncture for Chronic Lower Back Pain, (Dry Needling), MPM 57.0
- Allergen Immunotherapy, MPM 44.0
- Allergy Testing, MPM 45.0
- Ambulance Services, MPM 1.1
- Autism Spectrum Disorders: Diagnosis and Treatment, MPM 1.4
B
- Balloon Dilation for ENT Procedures, MPM 2.12
- Bariatric Surgery (Weight Loss Surgery) for Medicare, MPM 2.82
- Bariatric Surgery (Weight Loss Surgery) for Non-Medicare, MPM 2.81
- Bariatric Surgery for Pediatric Population, MPM 40.0
- Blepharoplasty/Ptosis Surgery, MPM 2.7
- Breast Surgical Procedures, MPM 27.0
- Bronchial Thermoplasty For Treatment of Asthma, See MPM 36.0
C
- Clinical Trials, Routine Patient Care Costs for Medicaid, MPM 3.7
- Capsule Endoscopy, MPM 24.0
- Chimeric Antigen Receptor (CAR) T-cell Therapy, MPM 32.0
- Clinical Trial, Routine Patient Care Costs for Medicare, MPM 3.8
- Clinical Trials, Routine Patient Care Costs for Commercial, MPM 3.6
- Corneal Cross-Linking for Keratoconus and Ectasia, MPM 28.0
- Cranial Orthotic Devices, (See DME: Orthotics and Prosthetics, MPM 4.6)
D
- Diapers for Medicaid Members, MPM 4.8
- Durable Medical Equipment: Bath Aids for Medicaid, MPM 48.0
- Durable Medical Equipment: Miscellaneous, MPM 4.5
- Durable Medical Equipment: Orthotics and Prosthetics, MPM 4.6
- Durable Medical Equipment: Positive Airway Pressure (PAP) and Oral Appliances for Treatment of Obstructive Sleep Apnea, MPM 49.1
- Durable Medical Equipment: Pneumatic Compression Devices, MPM 5.0
- Durable Medical Equipment: Rehabilitation and Mobility Devices, MPM 4.2
- Durable Medical Equipment: Respiratory Devices, MPM 4.3
F
- Facet Joint Interventions for Pain Management (Formerly Paravertebral Facet Joint Denervation), MPM 16.6
- Foot Splints for Club Foot (See DME: Orthotics and Prosthetics, MPM 4.6)
G
- Gastric Electric Stimulation for the Treatment of Chronic Gastroparesis, MPM 7.2
- Gender Affirming Treatment and Surgery (Adult, 18 years of age and older), MPM 7.3
- Gender Affirming Treatment for Children and Adolescent (17 y/o and under), MPM 7.31
- Genetic, Biomarker and Genomic Testing, MPM 7.1
- Genetic Testing for Breast Cancer Recurrence and Predictive, MPM 33.0
- Genetic Testing for Carrier Testing and Prenatal Diagnosis, MPM 7.13
- Genetic Testing for Circulating Tumor DNA Tests for Management of Cancer, MPM 54.0
- Genetic Testing for Cutaneous Melanoma, MPM 7.7
- Genetic Testing: Hypercoagulability/Thrombophilia, MPM 7.11
- Genetic Testing, InvisionFirst Liquid Biopsy for Lung Cancer, MPM 39.1 (Formerly MPM 37.0)
- Genetic Testing for Lynch Syndrome, MPM 7.5
- Genetic Testing: Next Generation Sequencing, MPM 29.0
- Genetic Testing for Non-Invasive Prenatal Testing (NIPT) (Formerly Non-Invasive Prenatal Testing (NIPT)), MPM 20.15
- Genetic Testing for Pancreatic Cyst (PathfinderTG®/PancraGen™), MPM 7.6
- Genetic Testing, Plasma-Based Genomic Profiling in Solid Tumors, MPM 39.0
- Genetic Testing for Prostate Cancer, MPM 7.8
- Genetic Testing for Uveal Melanoma, MPM 7.9
- Genetic Testing for Whole Exome Sequencing, MPM 7.12
H
- Home Health Care, for Medicare and Commercial, MPM 47.0
- Hyperbaric or Topical Oxygen Therapy (HBOT), MPM 8.6
- Hypoglossal Nerve Stimulator, MPM 46.0
I
- Interspinous Process Decompression (IPD) System (Formerly X-STOP® Interspinous Process Decompression (IPD) System), See MPM 36.0
- Intervertebral Differential Dynamics Therapy (IDD Therapy), See MPM 36.0
- Investigative & New Technology Assessment List (Non-Covered Services), MPM 36.0
L
- LINX Reflux Management System for the Treatment of GERD, See MPM 36.0
- Lumbar Artificial Disc Replacement, MPM 56.0
- Lymphedema and Lipedema Surgical Treatment, MPM 62.0
M
- Medicaid Home Health Services, MPM 13.6
- Mobile Cardiac Outpatient Telemetry™ (MCOT™) and Real-time Continuous Attended Cardiac Monitoring Systems, MPM 13.2
N
O
- Obstetric US 3D, 4D, 5D, MPM 15.4
- Osteogenic Bone Growth Stimulators, MPM 15.2
- Outpatient (in Facility) Observation, MPM 50.0
P
- Panniculectomy and Abdominoplasty, MPM 16.5
- Paravertebral Facet Joint Denervation (See Facet Joint Interventions for Pain Management, MPM 16.6)
- Percutaneous Neuromodulation Therapy, See MPM 36.0
- Peripheral Nerve Stimulation (Formerly Peripheral Nerve Stimulation for Occipital Neuralgia), MPM 53.0
- Pharmacogenomics Testing: Behavioral Health, for Medicare (Formerly Genesight Assay for Refractory Major Depression for Medicare), MPM 30.0
R
- Radiofrequency Ablation for Uterine Fibroid, MPM 8.9
- Restorative/Reconstructive/Cosmetic Surgery and Treatment, MPM 18.5
S
- Secca® Procedure for Fecal Incontinence, See MPM 36.0
- Sleep Studies, Attended (In-Laboratory) Full-Channel Polysomnography, MPM 49.0
- Subtalar Arthroereisis Implants for Pediatric Patients, See MPM 36.0
T
- Thermal Intradiscal Procedures (TIP), (includes IDET and Nucleoplasty) AKI: Intradiscal Electrothermal Therapy (IDET), See MPM 36.0
- Tissue-Engineered/Bioengineered Skin Substitutes (Application and Use), MPM 35.0
- Tonsillectomy, MPM 20.0
- Total Ankle Replacement, MPM 20.10
- Total Hip Resurfacing, MPM 20.9
- Total Joint Replacement Hip and Knee for Non-Medicare, MPM 20.14
- Total Joint Replacement Hip and Knee for Medicare, MPM 20.13
- Transcranial Magnetic Stimulation (TMS) for Treatment Resistant Depression, MPM 20.11
- Transoral Incisionless Fundoplication (TIF) for Treatment of GERD, MPM 20.12
