December 31, 2025
Effective 02/09/2026, we will be implementing a new medical policy: MN.028.A Inhaled Nitric Oxide. You can find the policy below.
Medical Policy Bulletins
Our medical policy bulletins define medical necessity criteria and coverage positions on topics such as medical services, procedures, durable medical equipment and therapies.
MN.004.C - New Technology
Documents coverage for new technology
Reviewed Date: 5/20/2026
MN.005.D - Experimental and Investigational (E&I) Services, Investigational Device Exemption (IDE), and Coverage with Evidence Development (CED) Documents our coverage position for E&I Services, IDEs, and CEDs
Reviewed Date: 6/17/2026
MN.006.I - Cosmetic & Reconstructive Services
Documents our coverage position for cosmetic and reconstructive services
Reviewed Date: 4/15/2026
MN.008.C - Genetic Testing
Documents our coverage position on genetic testing
Reviewed Date: 2/18/2026
MN.010.I - Gender-Affirming Surgery
Documents our position on gender-affirming surgery
Reviewed Date: 12/17/2025
MN.011.E - Whole Genome Sequencing (WGS)/Whole Exome Sequencing (WES)
Documents our coverage position on WGS and WES
Reviewed Date: 9/17/2025
MN.013.E - Shift Nursing, Personal Care, and Medical Daycare
Documents our position on the shift care, personal care, and medical daycare
Reviewed Date: 11/20/2025
MN.015.C - Standards of Medical Necessity
Documents our position related to medical necessity
Reviewed Date: 8/19/2026
MN.016.A - Injectable/Specialty Drugs Prior Authorization Requirements
Documents our prior authorization requirements for injectable/specialty drugs
Reviewed Date: 2/18/2026
MN.018.A - Medical Nutritional Support
Documents our policies on enteral nutrition
Reviewed Date: 10/15/2025
MN.020.C - Peroral Endoscopic Myotomy (POEM)
Documents our position related to POEM
Reviewed Date: 1/21/2026
MN.021.B - Panniculectomy and Abdominoplasty
Documents our position related to panniculectomy and abdominoplasty
Reviewed Date: 7/16/2025
MN.022.C - Reduction Mammoplasty
Documents our position related to reduction mammoplasty
Reviewed Date: 7/16/2025
MN.024.B - Relizorb (Immobilized Lipase Cartridge)
Documents our position related to Relizorb
Reviewed Date: 2/18/2026
MN.025.C - Speech Generating Devices
Documents our position related to Speech Generating Devices
Reviewed Date: 2/18/2026
MN.026.A - Continuous Glucose Monitors
Documents our position related to Continuous Glucose Monitors
Reviewed Date: 8/20/2025
MN.027.A - External Infusion Pump, Insulin
Documents our position related to External Infusion Pump, Insulin
Reviewed Date: 9/18/2025
MN.028.A - Inhaled Nitric Oxide
Documents our position related to Inhaled Nitric Oxide
Reviewed Date: 12/17/2025
MN.029.A - Autism Screening, Evaluation and Diagnosis
Reviewed Date: 2/18/2026