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Medical and Pharmacy Policies
Please read before continuing.
Medical policies are developed to assist in making coverage determinations under our health policies or plans. These policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in these policies.
Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific limitations and exclusions, and applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policies in their coverage determinations. For specific plan, benefit, and network status information, please contact Customer Service at the number listed on the member ID card.
Medical policies are based on constantly changing medical science, are reviewed annually, and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health to assist in administering health benefits. These medical policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.
For specific patient-related policy or medical coding inquiries, please contact the Medical Management Department with the patient’s name and ID card number, along with the procedure, service, or treatment in question.
Attn: Medical Management Department
P.O. Box 11625
Green Bay, WI 54307-1625
We welcome your feedback regarding medical policies or MCG Health guidelines.
For questions or comments regarding research and evidence development of a specific criteria, general medical policy, or MCG Health questions, contact the Medical Policy Committee at email@example.com.
To request an assessment of new technology or medical policy criteria by the Medical Policy Committee, please complete the New Technology and Medical Policy Assessment Request Form, attach supporting documentation from peer-reviewed high-level scientific literature, and email to the committee at firstname.lastname@example.org
For questions regarding medical coding related to policies, contact the Code Governance Committee at email@example.com.
NOTE: The email addresses above should NOT be used to send personal health records or member identified information. This disclaimer applies to all past and present medical and pharmacy policies.
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Click a medical policy you would like to view.
- Back Pain Procedures—Epidural Injections
- Back and Nerve Pain Procedures—Radiofrequency Ablation, Facet and Other Injection
- Back Pain—Sacroiliac Joint and Coccydynia Treatments
- Bariatric Surgery
- Biofeedback Treatment and Devices
- Blepharoplasty, Blepharoptosis, & Brow Lift
- Bone Growth Stimulators
- Capsule Endoscopy
- Cell-Free Fetal DNA Testing
- Chiropractic Services
- Cochlear Implants & Bone Anchored Hearing Aids
- Corneal Treatments and Specialized Contact Lenses
- Cranial Orthotic Device
- Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
- Magnetic Resonance Spectroscopy (MRS), Nuclear Magnetic Resonance Spectroscopy (NMRS)
- Meniscal Allograft Transplantation
- Microprocessor Controlled and Myoelectric Limb Prosthesis
- Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
- PET Scan (Positron Emission Tomography)
- Pneumatic Compression Devices
- Sleep Disorder Testing
- Sleep Disorder Treatment (Oral appliance and PAP device)
- Spinal Cord Stimulators
Medical Policy Updates