Oxford Health Plans > Practical Resources > Medical & Administrative Policy Index

Medical & Administrative Policy Index

A complete library of our clinical, administrative and reimbursement policies is available below for your reference. The appearance of an item or procedure on the list indicates only that we have adopted a policy; it does not imply that we provide coverage for the item or procedure listed.

The services described in our policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, our policies do not apply to Medicare Advantage enrollees. We reserve the right, in our sole discretion, to modify policies as necessary without prior written notice unless otherwise required by our administrative procedures or applicable state law. The terms "our" and "we" include Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to self-funded members and certain insured products. Refer to the member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


Policy Type Policy Title Effective Date
Clinical17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) 12/01/2018
ClinicalAblative Treatment for Spinal Pain 08/01/2018
ClinicalAbnormal Uterine Bleeding and Uterine Fibroids 12/01/2018
AdministrativeAbortions (Therapeutic and Elective) 10/01/2018
AdministrativeAccreditation Requirements for Radiology Services 12/01/2018
AdministrativeAcquired Rare Disease Drug Therapy Exception Process 02/01/2018
ClinicalActemra® (Tocilizumab) Injection for Intravenous Infusion 10/01/2018
ReimbursementAcupuncture 11/01/2018
ReimbursementAdd-On Policy 10/01/2018
ReimbursementAfter Hours and Weekend Care 10/01/2018
ClinicalAlpha1-Proteinase Inhibitors 11/01/2018
ReimbursementAmbulance 10/22/2018
AdministrativeAmbulance Services 06/01/2018
ClinicalApheresis 11/01/2018
AdministrativeAssignment of Benefits & Balance Billing 07/01/2018
ReimbursementAssistant Surgeon 12/01/2018
ClinicalAssisted Administration of Clotting Factors and Coagulant Blood Products 11/01/2018
ClinicalAthletic Pubalgia Surgery 12/01/2018
ClinicalAttended Polysomnography for Evaluation of Sleep Disorders 12/01/2018
AdministrativeAutism 10/01/2018
ClinicalAutologous Chondrocyte Transplantation in the Knee 12/01/2018
ReimbursementB Bundle Codes 11/01/2018
ClinicalBalloon Sinus Ostial Dilation 12/01/2018
ClinicalBariatric Surgery 11/01/2018
AdministrativeBehavioral Health Services 12/01/2018
ClinicalBenlysta® (Belimumab) 08/01/2018
ReimbursementBilateral Procedures 11/01/2018
ClinicalBlepharoplasty, Blepharoptosis and Brow Ptosis Repair 04/01/2018
ClinicalBone or Soft Tissue Healing and Fusion Enhancement Products 11/01/2018
ClinicalBotulinum Toxins A and B 12/01/2018
ClinicalBreast Imaging for Screening and Diagnosing Cancer 11/01/2018
ClinicalBreast Reconstruction Post Mastectomy 12/01/2018
ClinicalBreast Reduction Surgery 10/01/2018
ClinicalBreast Repair/Reconstruction Not Following Mastectomy 12/01/2018
ClinicalBrineura™ (Cerliponase Alfa) 07/01/2018
ClinicalBronchial Thermoplasty 12/01/2018
ClinicalBuprenorphine (Probuphine® & Sublocade™) 12/01/2018
ClinicalCardiology Procedures Requiring Precertification for eviCore healthcare Arrangement 12/01/2017
ClinicalCardiovascular Disease Risk Tests 07/01/2018
ReimbursementCare Plan Oversight 10/01/2018
ClinicalCarrier Testing for Genetic Diseases 11/01/2018
ClinicalChelation Therapy for Non-Overload Conditions 11/01/2018
ClinicalChemosensitivity and Chemoresistance Assays in Cancer 12/01/2018
ClinicalChromosome Microarray Testing (Non-Oncology Conditions) 10/01/2018
AdministrativeClaims Recovery 11/01/2017
AdministrativeClinical Review Policy 09/01/2017
ClinicalClinical Trials 07/01/2018
ClinicalClotting Factors and Coagulant Blood Products 12/01/2018
ClinicalCochlear Implants 11/01/2018
ClinicalCollagen Crosslinks and Biochemical Markers of Bone Turnover 11/01/2018
ClinicalComputerized Dynamic Posturography 12/01/2018
ReimbursementConsultation Services 07/01/2017
ClinicalContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes 10/01/2018
AdministrativeContraceptives 08/01/2018
AdministrativeCoordination of Benefits 02/01/2018
ClinicalCore Decompression for Avascular Necrosis 12/01/2018
ClinicalCorneal Hysteresis and Intraocular Pressure Measurement 12/01/2018
ClinicalCosmetic and Reconstructive Procedures 07/01/2018
ReimbursementCo-Surgeon/Team Surgeon 12/01/2018
AdministrativeCredentialing Guidelines: Participation in the eviCore healthcare Network 10/01/2017
ClinicalCrysvita® (Burosumab-Twza) 10/01/2018
ClinicalCytological Examination of Breast Fluids for Cancer Screening 12/01/2018
ClinicalDeep Brain and Cortical Stimulation 05/01/2018
ClinicalDenosumab (Prolia® & Xgeva®) 12/01/2018
AdministrativeDental and Oral Surgical Procedures 12/01/2018
AdministrativeDiabetes Supply Coverage for Commercial Plans (Including New Jersey Small Group Plans) 03/01/2017
AdministrativeDialysis Services 12/01/2017
AdministrativeDisclosure Policy 09/01/2018
ClinicalDiscogenic Pain Treatment 12/01/2018
ReimbursementDiscontinued Procedure 07/01/2018
ClinicalDrug Coverage Criteria - New and Therapeutic Equivalent Medications 12/01/2018
ClinicalDrug Coverage Guidelines 12/01/2018
ReimbursementDrug Testing 09/01/2018
AdministrativeDurable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements 07/01/2018
ReimbursementDurable Medical Equipment, Orthotics and Prosthetics Multiple Frequency 10/01/2018
ClinicalElbow Replacement Surgery (Arthroplasty) 10/01/2018
ClinicalElectric Tumor Treatment Field Therapy 12/01/2018
ClinicalElectrical and Ultrasound Bone Growth Stimulators 10/01/2018
ClinicalElectrical Bioimpedance for Cardiac Output Measurement 12/01/2018
ClinicalElectrical Stimulation and Electromagnetic Therapy for Wounds 02/01/2018
ClinicalElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 06/01/2018
ClinicalEloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business 11/01/2018
ClinicalEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome 12/01/2018
AdministrativeEmergency Room Visits (Including Coverage for Members Outside of the United States) 02/01/2017
ClinicalEntyvio® (Vedolizumab) 10/01/2018
ClinicalEnzyme Replacement Therapy 12/01/2018
ClinicalEpidural Steroid and Facet Injections for Spinal Pain 11/01/2018
ClinicalEpiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography 12/01/2018
ClinicalErythropoiesis-Stimulating Agents 11/01/2018
ReimbursementEvaluation and Management (E/M) 03/01/2018
ClinicalExondys 51™ (Eteplirsen) 10/01/2018
AdministrativeExperimental/Investigational Treatment 01/01/2018
ClinicalExperimental/Investigational Treatment for NJ Plans 02/01/2018
AdministrativeExtended Benefits for Total Disability & Succeeding Carrier for Inpatient Admissions 12/01/2017
ClinicalExtracorporeal Shock Wave Therapy (ESWT) 11/01/2018
ClinicalFecal Calprotectin Testing 11/01/2018
ClinicalFemoroacetabular Impingement Syndrome Treatment 01/01/2018
ClinicalFetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood 12/01/2018
AdministrativeFiling Deadlines for Claims Submissions 11/01/2017
ClinicalFollicle Stimulating Hormone (FSH) Gonadotropins 07/01/2018
AdministrativeFollow-Up Care Rendered in an Emergency Room Site of Service 10/01/2018
AdministrativeFormula & Specialized Food 08/01/2018
ReimbursementFrom - To Date Policy 10/01/2018
ClinicalFunctional Endoscopic Sinus Surgery (FESS) 10/01/2018
ClinicalGastrointestinal Motility Disorders, Diagnosis and Treatment 12/01/2018
ClinicalGender Dysphoria Treatment 11/01/2018
ClinicalGene Expression Tests for Cardiac Indications 11/01/2018
ClinicalGenetic Testing for Hereditary Cancer 10/01/2018
ClinicalGlaucoma Surgical Treatments 11/01/2018
ReimbursementGlobal Days 12/01/2018
ClinicalGonadotropin Releasing Hormone Analogs 12/01/2018
ClinicalGynecomastia Treatment 06/01/2018
ClinicalHearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable 05/01/2018
ClinicalHigh Frequency Chest Wall Compression Devices 12/01/2018
ClinicalHip Resurfacing and Replacement Surgery (Arthroplasty) 12/01/2018
ClinicalHome Health Care 09/01/2018
ClinicalHome Hemodialysis 03/01/2018
ClinicalHome Traction Therapy 12/01/2018
AdministrativeHospice Care 12/01/2017
ClinicalHuman Menopausal Gonadotropins (hMG) 07/01/2018
ClinicalHysterectomy for Benign Conditions 10/01/2018
ClinicalIlaris® (Canakinumab) 11/01/2018
ClinicalIlumya™ (Tildrakizumab-Asmn) 07/01/2018
ClinicalImmune Globulin (IVIG and SCIG) 12/01/2018
ClinicalImmune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion 04/01/2018
ClinicalImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors 05/01/2018
ClinicalImplanted Electrical Stimulator for Spinal Cord 04/01/2018
ReimbursementIncreased Procedural Services 11/01/2018
ClinicalInfertility Diagnosis and Treatment 06/01/2018
ClinicalInfliximab (Remicade®, Inflectra™, Renflexis™) 10/01/2018
ClinicalInjectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines 07/01/2018
ReimbursementInjection and Infusion Services 11/12/2018
AdministrativeIn-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy 09/01/2018
ReimbursementIn-Office Laboratory Testing and Procedures List 01/01/2018
AdministrativeInpatient Maternity Stay and Subsequent Home Nursing 12/01/2017
ClinicalIntraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) 11/01/2018
ClinicalIntrauterine Fetal Surgery 12/01/2018
ClinicalIntravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 10/01/2018
ClinicalLaser Interstitial Thermal Therapy 12/01/2018
ClinicalLemtrada (Alemtuzumab) 10/01/2018
ClinicalLight and Laser Therapy for Cutaneous Lesions and Pilonidal Disease 12/01/2018
ClinicalLithotripsy for Salivary Stones 12/01/2018
ClinicalLuxturna™ (Voretigene Neparvovec-Rzyl) 07/01/2018
ClinicalLyme Disease 12/01/2018
ClinicalMacular Degeneration Treatment Procedures 11/01/2018
ClinicalMagnetic Resonance Spectroscopy (MRS) 11/01/2018
ClinicalManipulation Under Anesthesia 11/01/2018
ClinicalManipulative Therapy 11/01/2018
ClinicalMaximum Dosage 05/01/2018
ReimbursementMaximum Frequency Per Day 12/01/2018
AdministrativeMechanical Circulatory Support Device (MCSD) 02/01/2018
ClinicalMechanical Stretching Devices 03/01/2018
AdministrativeMember Administrative Grievance and Appeal (Non UM) Process & Timeframes 12/01/2016
ClinicalMeniscus Implant and Allograft 11/01/2018
ReimbursementMicrosurgery 11/01/2017
ClinicalMifeprex® (Mifepristone) 06/01/2018
ClinicalMinimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) 12/01/2018
ReimbursementModifier Reference 11/01/2017
ReimbursementModifier SU 04/01/2018
ClinicalMolecular Oncology Testing for Cancer Diagnosis, Prognosis and Treatment Decisions 10/01/2018
ClinicalMotorized Spinal Traction 12/01/2018
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures 01/01/2018
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging 04/01/2018
ReimbursementMultiple Procedures 01/22/2018
ClinicalNerve Graft to Restore Erectile Function During Radical Prostatectomy 12/01/2018
ClinicalNeurophysiologic Testing and Monitoring 12/01/2018
ClinicalNeuropsychological Testing Under the Medical Benefit 11/01/2018
ReimbursementNew Patient Visit 10/01/2018
AdministrativeNew York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM) 06/01/2018
AdministrativeNew York Participating Provider Laboratory & Pathology Protocol 05/01/2017
AdministrativeNewborns 04/01/2018
AdministrativeNon-Participating Provider Consent Form Protocol 03/01/2018
ReimbursementNonphysician Health Care Codes 04/01/2018
ReimbursementNonphysician Health Care Professionals Billing Evaluation and Management Codes 01/01/2018
ClinicalObservation Care 04/01/2018
ReimbursementObservation Care Evaluation and Management Codes 04/01/2018
ReimbursementObstetrical Policy 11/12/2018
ClinicalObstetrical Ultrasonography 10/01/2018
ClinicalObstructive Sleep Apnea Treatment 10/01/2018
ClinicalOccipital Neuralgia and Headache Treatment 11/01/2018
ClinicalOcrevus™ (Ocrelizumab) 12/01/2018
ClinicalOffice Based Program 12/01/2018
ClinicalOff-Label/Unproven Specialty Drug Treatment 07/01/2018
ClinicalOmnibus Codes 10/01/2018
ReimbursementOnce In a Lifetime Procedures 05/01/2018
ReimbursementOne or More Sessions 11/01/2018
ClinicalOnpattro™ (Patisiran) 09/01/2018
ClinicalOrencia® (Abatacept) Injection for Intravenous Infusion 12/01/2018
ClinicalOrthognathic (Jaw) Surgery 10/01/2018
AdministrativeOrthopedic Services 10/01/2018
ClinicalOsteochondral Grafting 10/01/2018
ClinicalOtoacoustic Emissions Testing 10/01/2018
ClinicalOutpatient Cardiac Telemetry 11/01/2018
ClinicalOutpatient Physical & Occupational Therapy for Self-Funded Groups 03/01/2018
ClinicalOutpatient Physical and Occupational Therapy (OptumHealth Care Solutions Arrangement) 07/01/2018
ClinicalOxford's Outpatient Imaging Self-Referral 12/01/2018
ClinicalPanniculectomy and Body Contouring Procedures 10/01/2018
AdministrativePar Gastroenterologists Using Nhesiologists: In-Office & Ambulatory Surgery Centers 05/01/2017
ClinicalParsabiv™ (Etelcalcetide) 10/01/2018
ClinicalPectus Deformity Repair 08/01/2018
ReimbursementPediatric and Neonatal Critical and Intensive Care Services 01/01/2018
ClinicalPercutaneous Vertebroplasty and Kyphoplasty 10/01/2018
ClinicalPharmacogenetic Testing 11/01/2018
ReimbursementPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction 07/01/2018
ClinicalPhysical, Occupational (OptumHealth Care Solutions Arrangement) and Speech Therapy including Cognitive/Neuropsychological Rehabilitation for New Jersey Small Group Members 08/01/2018
ReimbursementPhysician Extenders 12/01/2018
ClinicalPlagiocephaly and Craniosynostosis Treatment 12/01/2018
ClinicalPlatelet Derived Growth Factors for Treatment of Wounds 12/01/2018
ClinicalPneumatic Compression Devices 10/01/2018
AdministrativePractitioner/Provider Administrative Claim Reconsideration and Appeal Process 12/01/2016
AdministrativePrecertification Exemptions for Outpatient Services 10/01/2018
ClinicalPreterm Labor Management 12/01/2018
ClinicalPreventive Care Services 10/01/2018
ReimbursementPreventive Medicine and Screening 07/01/2018
ClinicalPrivate Duty Nursing Services (PDN) 08/01/2018
ReimbursementProcedure and Place of Service 12/01/2018
ReimbursementProlonged Services 05/01/2018
ClinicalProlotherapy for Musculoskeletal Indications 12/01/2018
ClinicalProsthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 12/01/2018
ClinicalRadiation Therapy Procedures Requiring Precertification for eviCore heathcare Arrangement 07/01/2018
ClinicalRadicava™ (Edaravone) 12/01/2018
ClinicalRadiology Procedures Requiring Precertification for eviCore heathcare Arrangement 11/01/2018
ClinicalRadiopharmaceuticals and Contrast Media 07/01/2018
ReimbursementReduced Services 07/01/2018
AdministrativeReferrals 04/01/2018
ReimbursementReimbursement for Comprehensive and Component CPT Codes 03/01/2018
ReimbursementReplacement Codes 01/22/2018
ClinicalRepository Corticotropin Injection (H.P. Acthar Gel®) 06/01/2018
AdministrativeRequests for In-Network Exceptions 09/01/2018
ClinicalRespiratory Interleukins (Cinqair®, Fasenra®, and Nucala®) 10/01/2018
ClinicalReview at Launch for New to Market Medications 01/01/2018
ClinicalRhinoplasty and Other Nasal Surgeries 08/01/2018
ClinicalRituxan® (Rituximab) 12/01/2018
ReimbursementRobotic Assisted Surgery 11/01/2018
ClinicalRoutine Foot Care 07/01/2018
ReimbursementSame Day/Same Service 10/01/2018
ClinicalSandostatin LAR® Depot (Octreotide Acetate) 12/01/2018
ClinicalSensory Integration Therapy and Auditory Integration Training 12/01/2018
ReimbursementServices and Modifiers Not Reimbursable to Healthcare Professionals 09/01/2018
AdministrativeServices Requiring Prior Authorization 10/01/2018
ClinicalShoulder Replacement Surgery (Arthroplasty) 10/01/2018
ClinicalSimponi® Aria (Golimumab) Injection for Intravenous Infusion 12/01/2018
ReimbursementSite of Service Differential 09/01/2018
ClinicalSite of Service Guidelines for Certain Outpatient Surgical Procedures 05/01/2018
AdministrativeSkilled Care and Custodial Care Services 09/01/2018
ClinicalSkin and Soft Tissue Substitutes 12/01/2018
ClinicalSodium Hyaluronate 08/01/2018
ClinicalSoliris® (Eculizumab) 08/01/2018
ClinicalSpecialty Medication Administration - Site of Care Review Guidelines 10/01/2018
ReimbursementSpecialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting 10/01/2018
AdministrativeSpeech Therapy and Early Intervention Programs/Birth to Three 10/01/2018
ClinicalSpinraza™ (Nusinersen) 04/01/2018
ReimbursementSplit Surgical Package 07/01/2018
ReimbursementStandby Services 04/01/2018
ClinicalStelara® (Ustekinumab) 10/01/2018
ReimbursementSupply Policy 11/12/2018
ClinicalSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 11/01/2018
ClinicalSurgical Treatment for Spine Pain 10/01/2018
ClinicalSynagis® (Palivizumab) 12/01/2018
ReimbursementT Status Codes 11/01/2018
ReimbursementTelehealth and Telemedicine 12/01/2018
ClinicalTemporomandibular Joint Disorders 04/01/2018
ClinicalThermography 12/01/2018
ReimbursementTime Span Codes 08/20/2018
AdministrativeTimeframe Standards for Benefit Administrative Initial Decisions 11/01/2018
AdministrativeTimeframe Standards for Utilization Management (UM) Initial Decisions 11/01/2018
ClinicalTotal Artificial Disc Replacement for the Spine 11/01/2018
ClinicalTotal Artificial Heart 11/01/2018
ClinicalTotal Knee Replacement Surgery (Arthroplasty) 10/01/2018
ClinicalTranscatheter Heart Valve Procedures 12/01/2018
ClinicalTranscranial Magnetic Stimulation 04/01/2018
ClinicalTranspupillary Thermotherapy 11/01/2018
ClinicalTrogarzo™ (Ibalizumab-Uiyk) 07/01/2018
ClinicalUmbilical Cord Blood Harvesting and Storage for Future Use 11/01/2018
ClinicalUnicondylar Spacer Devices for Treatment of Pain or Disability 11/01/2018
ReimbursementUrgent Care 02/01/2018
ClinicalVaccines 05/01/2018
ClinicalVagus Nerve Stimulation 10/01/2018
ClinicalVirtual Upper Gastrointestinal Endoscopy 12/01/2018
AdministrativeVision Services (Including Refractive Surgery) 09/01/2018
ClinicalVisual Information Processing Evaluation and Orthoptic and Vision Therapy12/01/2018
ClinicalWarming Therapy and Ultrasound Therapy for Wounds 12/01/2018
ClinicalWhite Blood Cell Colony Stimulating Factors 12/01/2018
ClinicalWhole Exome and Whole Genome Sequencing 10/01/2018
ReimbursementWrong Surgical or Other Invasive Procedures 03/01/2018
ClinicalXolair® (Omalizumab) 12/01/2018

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