UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies
The Clinical Policies, Administrative Policies, Reimbursement Policies and corresponding update bulletins for UnitedHealthcare Oxford plans are listed below.
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A monthly notice of recently approved and/or revised Clinical Policies, Administrative Policies and Reimbursement Policies is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device or procedure) in the Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
03/01/2020 - Oxford Policy Update Bulletin: March 2020
Last Published 03.01.2020
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
04/01/2020 - Oxford Policy Update Bulletin: April 2020
Last Published 04.01.2020
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
05/01/2020 - Oxford Policy Update Bulletin: May 2020
Last Published 05.01.2020
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Oxford Policy Update Bulletin Archive
Last Published 05.20.2020
Current Policies
UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies
Please read the terms and conditions below carefully.
A complete library of the UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies is available here 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. 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.
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Abnormal Uterine Bleeding and Uterine Fibroids – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58578, 58674, 58999, J7296, J7297, J7298, J7301, J7306, S4981.
Actemra® (Tocilizumab) Injection for Intravenous Infusion – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Actemra® (tocilizumab) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis, and cytokine release syndrome. Applicable Procedure Code: J3262.
Adakveo® (Crizanlizumab-Tmca) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of Adakveo® (crizanlizumab-tmca) to reduce the frequency of vasoocclusive crises in patients with sickle cell disease. Applicable Procedure Codes: C9053, J3490, J3590.
After Hours and Weekend Care – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses procedure codes for after hours and weekend care services. Applicable Procedure Codes: 99050, 99051, 99053, 99056, 99058, 99060.
Ambulance – Oxford Reimbursement Policy
Last Published 02.01.2020
Effective Date: 02.01.2020 – This policy addresses services included as part of an ambulance transportation service, ambulance modifier usage, provider specialty reporting ambulance services, and the requirements for reporting Advanced Life Support: Level 2 (ALS2) ambulance transportation.
Anesthesia (CES) – Oxford Reimbursement Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses procedural or pain management services that are an integral part of anesthesia services, as well as anesthesia services that are an integral part of procedural services.
Articular Cartilage Defect Repairs – Oxford Clinical Policy
Last Published 02.12.2020
Effective Date: 01.01.2020 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, microfracture repair of the knee, and focal articular cartilage repair. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Assistant-at-Surgery – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 01.21.2020 – This policy addresses services performed by an assistant for a physician performing a surgical procedure.
Attended Polysomnography for Evaluation of Sleep Disorders – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Balloon Sinus Ostial Dilation – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 01.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.
Bariatric Surgery – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, gastric sleeve procedure, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Bilateral Procedures (CES) – Oxford Reimbursement Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses unilateral procedures that can be performed on both sides of the body during the same session by the same individual physician or other qualified health care professional, including procedure codes with bilateral in their intent or "bilateral" in the description.
Blepharoplasty, Blepharoptosis and Brow Ptosis Repair – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES).
Botulinum Toxins A and B – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588.
Breast Reconstruction Post Mastectomy – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 02.01.2020 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0295T, 0296T, 0297T, 0298T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Breast Reduction Surgery – Oxford Clinical Policy
Last Published 05.20.2020
Effective Date: 05.01.2020 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Breast Repair/Reconstruction Not Following Mastectomy – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 11.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Cardiac Event Monitoring – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0295T, 0296T, 0297T, 0298T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Cardiovascular Disease Risk Tests – Oxford Clinical Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0111T, 0126T, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Clinical Trials - Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Co-Surgeon/Team Surgeon (CES) - Oxford Reimbursement Policy
Last Published 01.21.2020
Effective Date: 01.21.2020 – This policy addresses co-surgeon and team surgeon services.
Collagen Crosslinks and Biochemical Markers of Bone Turnover – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Computerized Dynamic Posturography - Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Contraceptives – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses contraceptive procedures/appliances/devices and injectable drugs provided in a physician’s office.
Cosmetic and Reconstructive Procedures – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 02.01.2020 – This policy addresses cosmetic and reconstructive procedures.
Cytological Examination of Breast Fluids for Cancer Screening – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Denosumab (Prolia® & Xgeva®) – Oxford Clinical Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.
Dental and Oral Surgical Procedures – Oxford Administrative Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses oral surgical and dental procedures and related anesthesia when determined to be medical in nature.
Dialysis Services – Oxford Administrative Policy
Last Published 04.01.2020
Effective Date: 03.01.2020 – This policy addresses dialysis services. Applicable Procedure Codes: 90935, 90937, 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90967, 90968, 90969, 90970, 90989, 90993, 90997, 90999, G0257, G0491, G0492.
Drug Coverage Criteria – New and Therapeutic Equivalent Medications – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses medications for which certain types of prescription drug benefit exclusions may apply.
Drug Coverage Guidelines - Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses multiple drug coverage guidelines.
Drug Testing – Oxford Reimbursement Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the daily limit for presumptive and definitive drug testing, and specimen validity testing.
Elbow Replacement Surgery (Arthroplasty) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.
Electrical and Ultrasound Bone Growth Stimulators – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses electrical, electromagnetic, and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20975, 20979, E0747, E0748, E0749, E0760.
Electrical Stimulation and Electromagnetic Therapy for Wounds – Oxford Clinical Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses electrical stimulation and electromagnetic therapy for treating ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Electroencephalographic (EEG) Monitoring and Video Recording – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Entyvio® (Vedolizumab) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Entyvio® (vedolizumab) for the treatment of Crohn's disease, ulcerative colitis, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3380.
Epidural Steroid and Facet Injections for Spinal Pain – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses epidural steroid and facet injections for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0230T, 0231T, 62322, 62323, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495.
Exondys 51® (Eteplirsen) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.
Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses DNA-based noninvasive prenatal tests of fetal aneuploidy. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.
Functional Endoscopic Sinus Surgery (FESS) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 11.01.2019 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.
Genetic Testing for Neuromuscular Disorders – Oxford Clinical Policy
Last Published 10.01.2019
Effective Date: 10.01.2019 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81443, 81440, 81460, 81465, 81479.
Givlaari® (Givosiran) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Codes: C9056, J3490, J3590.
Global Days – Oxford Reimbursement Policy
Last Published 01.21.2020
Effective Date: 01.21.2020 – This policy addresses the timeframe (global days) that applies to certain procedures subject to a global surgical package concept whereby all necessary services normally furnished by a physician (before, during, and after the procedure) are included in the reimbursement for the procedure performed.
Gonadotropin Releasing Hormone Analogs – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J3315, J3316, J9155, J9202, J9217, J9225, J9226.
Gynecomastia Treatment – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Hip Resurfacing and Replacement Surgery (Arthroplasty) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.
Home Health Care – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses home health care services.
Home Hemodialysis – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Hysterectomy for Benign Conditions – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58550, 58552, 58553, 58554.
Ilumya™ (Tildrakizumab-Asmn) - Oxford Clinical Policy
Last Published 09.01.2019
Effective Date: 09.01.2019 – This policy addresses the use of provider-administered Ilumya™ (tildrakizumab-asmn) for the treatment of moderate to severe plaque psoriasis. Applicable Procedure Code: J3245.
Immune Globulin (IVIG and SCIG) – Oxford Clinical Policy
Last Published 05.20.2020
Effective Date: 04.01.2020 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1555, J1556, J1557, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.
Immune Globulin - Site of Care – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses hospital outpatient facility infusion services for intravenous immune globulin (IVIG) and subcutaneous immune globulin (SCIG) therapy.
Implantable Beta Emitting Microspheres for Treatment of Malignant Tumors – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.
Implanted Electrical Stimulator for Spinal Cord – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Increased Procedural Services (CES) – Oxford Reimbursement Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses services provided by a health care professional that are substantially greater than typically required for the services, including the use of modifiers 22 (increased procedural service) and 63 (procedure performed on infants less than 4 kilograms).
Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of infliximab products, including Avsola™ (infliximab-axxq), Inflectra® (infliximab-dyyb), Remicade® (infliximab), and Renflexis® (infliximab-abda). Applicable Procedure Codes: J1745, J3490, J3590, Q5103, Q5104, Q5109.
Inhaled Nitric Oxide for Infants – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.
Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses parameters for coverage of injectable oncology medications and select ancillary and supportive care medications for oncology conditions covered under the medical benefit.
Injection and Infusion Services (CES) – Oxford Reimbursement Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses therapeutic and diagnostic injection and infusion services when reported with evaluation and management (E/M) services, including related supplies and/or drugs.
Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: C9399, J1439, J3490, Q0138.
Knee Replacement Surgery (Arthroplasty), Total and Partial – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.
Krystexxa® (Pegloticase) – Oxford Clinical Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.
Lemtrada (Alemtuzumab) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Lemtrada (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.
Lower Extremity Vascular Angiography – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses lower extremity vascular angiography for evaluating arterial disease of the lower extremity. Applicable Procedure Codes: 75710, 75716.
Luxturna™ (Voretigene Neparvovec-Rzyl) – Oxford Clinical Policy
Last Published 05.20.2020
Effective Date: 11.01.2019 – This policy addresses the use of Luxturna™ (voretigene neparvovec-rzyl) for the treatment of inherited retinal dystrophies (IRD) caused by mutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene. Applicable Procedure Code: J3398.
Manipulation Under Anesthesia – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Maximum Dosage – Oxford Clinical Policy
Last Published 11.01.2019
Effective Date: 11.01.2019 – This policy addresses the maximum dosage per administration for medications administered by a medical professional. Applicable Procedure Codes: J0222, J0717, J0897, J1300, J1303, J1745, J2357, J2505, J3357, J3358, J3380, J3489, J9035, J9299, J9312, J9355, Q5103, Q5104, Q5107, Q5108, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118.
Maximum Frequency Per Day (CES) – Oxford Reimbursement Policy
Last Published 04.13.2020
Effective Date: 04.13.2020 – This policy addresses maximum frequency per day determinations for services/procedures.
Mechanical Circulatory Support Device (MCSD) – Oxford Administrative Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of long term, durable mechanical circulatory support devices. Applicable Procedure Codes: 33975, 33976, 33979, 33981, 33982, 33983.
Meniscus Implant and Allograft – Oxford Clinical Policy
Last Published 09.23.2019
Effective Date: 06.01.2019 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Microsurgery (CES) – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses use of an operating microscope during a surgical procedure. Applicable Procedure Codes: 64727, 69990.
Mifeprex® (Mifepristone) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Mifeprex® (mifepristone) in combination with misoprostol for medical termination of intrauterine pregnancy. Applicable Procedure Codes: S0190, S0191.
Modifier SU Policy – Oxford Reimbursement Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses reimbursement for claims appended with modifier SU.
Mohs Micrographic Surgery – Oxford Reimbursement Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses Mohs micrographic surgery, including excision and pathology services. Applicable Procedure Codes: 17311, 17312, 17313, 17314, 17315.
Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures
Last Published 03.01.2020
Effective Date: 02.01.2020 – This policy addresses when multiple diagnostic cardiovascular procedures or diagnostic ophthalmology procedures are performed on the same day.
Multiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services – Oxford Reimbursement Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses multiple medical or surgical procedures performed on the same day by the same group physician and/or other health care professional.
Newborns – Oxford Administrative Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses enrollment and coverage of newborns.
Nonphysician Health Care Codes – Oxford Reimbursement Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses nonphysician health care professional service codes. Applicable Procedure Codes: 96040, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, 97802, 97803, 97804, 98960, 98961, 98962, 99605, 99606, 99607, G0270, G0271, G2061, G2062, G2063.
Nonphysician Health Care Professionals Billing Evaluation and Management Codes – Oxford Reimbursement Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses evaluation and management (E/M) services reported by nonphysician health care professionals.
Observation and Discharge – Oxford Reimbursement Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses observation care services and discharge day management. Applicable Procedure Codes: 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236, 99238, 99239.
Observation Care – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses observation care.
Obstetrical Policy – Oxford Reimbursement Policy
Last Published 04.13.2020
Effective Date: 04.13.2020 – This policy addresses global obstetrical (OB) codes and itemization of maternity care services. Applicable Procedure Codes: 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622.
Obstetrical Ultrasonography – Oxford Clinical Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses obstetrical ultrasounds. Applicable Procedure Codes: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828.
Obstructive Sleep Apnea Treatment – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, L8679, L8680, L8686, S2080.
Occipital Neuralgia and Headache Treatment – Oxford Clinical Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses occipital neuralgia and headache treatments, including injection of local anesthetics and/or steroids used as occipital nerve blocks, neurostimulation or electrical stimulation, occipital neurectomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy, and surgical nerve decompression. Applicable Procedure Codes: 62281, 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, L8679, L8680, L8685.
Off-Label/Unproven Specialty Drug Treatment – Oxford Clinical Policy
Last Published 04.06.2020
Effective Date: 07.01.2019 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.
Office Based Procedures - Site of Service – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses certain elective procedures that are typically performed in an office setting but may be performed in an ambulatory surgical center in certain circumstances. Applicable Procedure Codes: 11402, 11403, 11406, 11422, 11426, 11442, 19000, 27096, 31579, 57460, 62270, 62321, 64479, 64490, 64493, 64633, 64635.
Omnibus Codes – Oxford Clinical Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses multiple services/procedures.
Once in a Lifetime Procedures – Oxford Reimbursement Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses certain procedures reimbursed only once during a patient’s lifetime.
Onpattro™ (Patisiran) – Oxford Clinical Policy
Last Published 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of Onpattro™ (patisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedure Code: J0222.
Orthognathic (Jaw) Surgery – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses orthognathic (jaw) surgery.
Orthopedic Services – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses services subject to utilization review with OrthoNet’s orthopedic division.
Outpatient Physical & Occupational Therapy for Self-Funded Groups – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses outpatient physical and occupational therapy for self-funded groups.
Outpatient Physical and Occupational Therapy (OptumHealth Care Solutions Arrangement) - Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses outpatient physical and occupational therapy for OptumHealth Care Solutions arrangements.
Outpatient Surgical Procedures - Site of Service – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses sites of service for certain outpatient surgical procedures.
Oxford's Outpatient Imaging Self-Referral – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses self-referral for outpatient imaging services.
Panniculectomy and Body Contouring Procedures – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Parsabiv® (Etelcalcetide) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Participating Gastroenterologists Using Non-Participating Anesthesiologists: In-Office and Ambulatory Surgery Centers Protocol – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses participating gastroenterologists located in New York performing non-emergent procedures using nonparticipating anesthesiologists in office (IO) or in an ambulatory surgery center (ASC).
Participating Providers Using Non-Participating Laboratory and Pathology Providers Protocol – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses participating providers treating a member on a Connecticut (CT) or New York (NY) product and wants to use a non-participating laboratory/pathologist or wants to provide the member with a form to obtain laboratory/pathology services outside the physician office.
Participating Providers Using Non-Participating Providers Protocol – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses a participating provider's use of a non-participating provider physician, facility, or other healthcare provider in a member’s care, and the Member Advanced Notice Form.
Participating Surgeons Using Non-Participating Assistant Surgeons and Co-Surgeons Protocol – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses participating surgeons located in New York using non-participating assistant surgeons and co-surgeons for non-emergent procedures.
Participating Surgeons Using Non-Participating Providers for Intraoperative Neuro-Monitoring (IONM) Protocol – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses participating providers in New York and Connecticut using non-participating providers for intraoperative neuro-monitoring (IONM).
Pectus Deformity Repair – Oxford Clinical Policy
Last Published 07.15.2019
Effective Date: 07.01.2019 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Pediatric and Neonatal Critical and Intensive Care Services – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 12.01.2019 – This policy addresses pediatric and neonatal critical and intensive care services. Applicable Procedure Codes: 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480.
Percutaneous Patent Foramen Ovale (PFO) Closure – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.
Percutaneous Vertebroplasty and Kyphoplasty – Oxford Clinical Policy
Last Published 11.22.2019
Effective Date: 09.01.2019 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.
Pharmacogenetic Testing – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 02.01.2020 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 81479.
Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses reimbursement for the Practice Expense (PE) portions of certain therapy procedures when those services are the secondary or subsequent procedures provided on a single date of service by the same group physician and/or other health care professional.
Physical, Occupational (OptumHealth Care Solutions Arrangement) and Speech Therapy Including Cognitive/ Neuropsychological Rehabilitation for New Jersey Small Group Members – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses physical, occupational, speech, and cognitive therapy and therapeutic manipulation for New Jersey Small Group members.
Physician Extenders – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 12.01.2019 – This policy addresses physician extender eligibility for reimbursement of surgical and non-surgical services.
Plagiocephaly and Craniosynostosis Treatment – Oxford Clinical Policy
Last Published 11.22.2019
Effective Date: 10.01.2019 – This policy addresses the use of cranial orthotic devices for treating infants with plagiocephaly and craniosynostosis. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Pneumatic Compression Devices – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Precertification Exemptions for Outpatient Services – Oxford Administrative Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses services which are exempt from the standard outpatient precertification requirement.
Preimplantation Genetic Testing - Oxford Clinical Policy
Last Published 11.01.2019
Effective Date: 06.01.2019 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 81228, 81229, 81479.
Preventive Care Services – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 02.01.2020 – This policy addresses preventive care services.
Preventive Medicine and Screening (CES) - Oxford Reimbursement Policy
Last Published 06.01.2019
Effective Date: 06.01.2019 – This policy addresses preventive medicine and screening services.
Private Duty Nursing (PDN) Services – Oxford Clinical Policy
Last Published 08.01.2019
Effective Date: 08.01.2019 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Code: T1000.
Procedure and Place of Service – Oxford Reimbursement Policy
Last Published 04.13.2020
Effective Date: 04.13.2020 – This policy addresses procedure codes that include the place of service (POS) in their description or where coding guidelines are provided relative to POS.
Procedure to Modifier Policy (CES) – Oxford Reimbursement Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses the appropriate use of modifiers with individual CPT and HCPCS procedure codes.
Procedure/Technical Component (CES) – Oxford Reimbursement Policy
Last Published 02.12.2020
Effective Date: 01.01.2020 – This policy addresses services with professional and/or technical component indicators, as well as information pertaining to duplicate/repeat services, modifier usage, services based on place of service (POS), and the professional component with an evaluation and management service.
Prolonged Services – Oxford Reimbursement Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses prolonged services when reported in conjunction with companion evaluation and management (E/M) codes or other services. Applicable Procedure Codes: 99354, 99355, 99356, 99357, 99358, 99359, 99415, 99416, G0513, G0514.
Prolotherapy and Platelet Rich Plasma Therapies – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055.
Provider Administered Drugs - Site of Care – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses outpatient hospital facility-based intravenous medication infusion. Applicable Procedure Codes: J0129, J0180, J0221, J0222, J0256, J0257, J0490, J0517, J0584, J0638, J1300, J1301, J1303, J1322, J1428, J1458, J1602, J1743, J1745, J1746, J1786, J1931, J2182, J2350, J2786, J2840, J3060, J3245, J3262, J3380, J3385, J3397, J3590, Q5103, Q5104.
Radiation Therapy Procedures Requiring Precertification for eviCore healthcare Arrangement – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 03.01.2019 – This policy addresses radiation therapy services which require precertification by eviCore healthcare.
Radicava® (Edaravone) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses radiology procedures which require precertification by eviCore healthcare, including computerized axial tomography (CAT) scan, CT colonography/virtual colonoscopy (for diagnostic purposes), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), nuclear medicine imaging, positron emission tomography (PET) scans, and obstetrical ultrasound.
Radiopharmaceuticals and Contrast Media – Oxford Clinical Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses radiopharmaceuticals and contrast media administered by eviCore healthcare.
Reblozyl® (Luspatercept-Aamt) – Oxford Clinical Policy
Last Published 03.01.2020
Effective Date: 02.01.2020 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia. Applicable Procedure Codes: C9399, J3490, J3590.
Reduced Services (CES) – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 02.01.2020 – This policy addresses the use of modifier 52 (reduced services) for services or procedures that are partially reduced or eliminated at the discretion of the qualified health care professional.
Referrals – Oxford Administrative Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses referrals to a specialist, hospital, or ancillary provider.
Reimbursement for Comprehensive and Component CPT Codes (CES) – Oxford Reimbursement Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses the payment methodology utilized by Oxford in determining claims reimbursement when multiple procedures are performed in the same session by the same provider.
Replacement Codes – Oxford Reimbursement Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses specific codes assigned status code "I" on the National Physician Fee Schedule (NPFS) where the Centers for Medicare and Medicaid Services (CMS) has indicated a replacement code is available and has assigned a Relative Value Unit (RVU) to the replacement code. Applicable Procedure Codes: 44705, 77387, 77387, 77402, 77407, 77412, 95941, 97014, 98970, 98971, 98972, G0455, G2061, G2062, G2063, G6001, G6002, G6003, G6007, G6011, G0453, G0283.
Requests for In-Network Exceptions – Oxford Administrative Policy
Last Published 11.22.2019
Effective Date 09.01.2018 – This policy addresses the review of in-network exception requests for members residing within Oxford's service area.
Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of interleukin-5 (IL-5) antagonists, including Cinqair® (reslizumab), Fasenra® (benralizumab), and Nucala® (mepolizumab). Applicable Procedure Codes: J0517, J2182, J2786.
Review at Launch for New to Market Medications – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 10.01.2019 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Rhinoplasty and Other Nasal Surgeries – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, and septal dermatoplasty. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30560, 30620.
Rituximab (Rituxan®, Ruxience™, & Truxima®) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of Rituxan® (rituximab), Ruxience™ (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J3490, J3590, J9311, J9312, Q5115.
Routine Foot Care – Oxford Clinical Policy
Last Published 11.22.2019
Effective Date: 10.01.2019 – This policy addresses routine foot care for members with diabetes or who are at risk for neurological or vascular disease arising from diseases such as diabetes.
Same Day/Same Service (CES) – Oxford Reimbursement Policy
Last Published 07.01.2019
Effective Date: 07.01.2019 – This policy addresses multiple medical and/or evaluation and management (E/M) services for a patient on a single date of service.
Sandostatin LAR® Depot (Octreotide Acetate) – Oxford Clinical Policy
Last Published 11.22.2019
Effective Date: 11.01.2019 – This policy addresses the use of Sandostatin LAR® (octreotide acetate LAR). Applicable Procedure Code: J2353.
Sensory Integration Therapy and Auditory Integration Training – Oxford Clinical Policy
Last Published 11.22.2019
Effective Date: 09.01.2019 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Services and Modifiers Not Reimbursable to Healthcare Professionals – Oxford Reimbursement Policy
Last Published 01.01.2020
Effective Date: 01.01.2020 – This policy addresses services and modifiers not reimbursable to healthcare professionals.
Services Requiring Prior Authorization – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses services requiring prior authorization and their related policies.
Shoulder Replacement Surgery (Arthroplasty) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses shoulder replacement surgery (arthroplasty and hemiarthroplasty). Applicable Procedure Codes: 23470, 23472, 23473, 23474.
Simponi Aria® (Golimumab) Injection for Intravenous Infusion – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses Simponi Aria® (golimumab) injection for intravenous infusion for the treatment of ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis. Applicable Procedure Code: J1602.
Site of Service Differential – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses a site of service differential that reduces practice expense payments for services provided in facility or ambulance settings.
Skilled Care and Custodial Care Services – Oxford Administrative Policy
Last Published 11.22.2019
Effective Date: 08.01.2019 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Skin and Soft Tissue Substitutes – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 01.01.2020 – This policy addresses skin and soft tissue substitutes.
Sodium Hyaluronate – Oxford Clinical Policy
Last Published 02.11.2020
Effective Date: 01.01.2020 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting - Oxford Reimbursement Policy
Last Published 04.01.2020
Effective Date: 04.01.2019 – This policy addresses certain specialty medications provided in an outpatient hospital setting that must be obtained from the designated specialty pharmacy. Applicable Procedure Codes: J0129, J0202, J0717, J1602, J1745, J2323, J2350, J3262, J3357, J3358, J3380, Q5103, Q5104.
Speech Therapy and Early Intervention Programs/Birth to Three – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses speech therapy and early intervention/birth to three programs. Applicable Procedure Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92610, 92626, 92627, 92700, G0153, H2014, H2015, H2019, S9128, S9152, T1015, T1023, T1024, T1025, T1026, T1027, T1028, T2024.
Spinraza™ (Nusinersen) – Oxford Clinical Policy
Last Published 11.22.2019
Effective Date: 06.01.2019 – This policy addresses the use of Spinraza™ (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.
Split Surgical Package (CES) – Oxford Reimbursement Policy
Last Published 02.12.2020
Effective Date: 12.01.2019 – This policy addresses split surgical package situations.
Spravato™ (Esketamine) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of Spravato™ (esketamine) for the treatment of treatment-resistant depression (TRD). Applicable Procedure Code: J3490.
Standby Services – Oxford Reimbursement Policy
Last Published 02.11.2020
Effective Date: 12.01.2019 – This policy addresses standby services and hospital mandated on-call services. Applicable Procedure Codes: 99026, 99027, 99360.
Stelara® (Ustekinumab) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Stelara® (ustekinumab) for the treatment of Crohn’s disease, plaque psoriasis, psoriatic arthritis, and ulcerative colitis. Applicable Procedure Codes: J3357, J3358.
Supply Policy – Oxford Reimbursement Policy
Last Published 02.01.2020
Effective Date: 02.01.2020 – This policy addresses codes representing supplies, drugs, and other items based on the place of service (POS) submitted on the claim.
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins – Oxford Clinical Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37780, 37799.
Surgical Treatment for Spine Pain – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses surgical treatment for spine pain.
Synagis® (Palivizumab) – Oxford Clinical Policy
Last Published 11.22.2019
Effective Date: 08.01.2019 – This policy addresses the use of Synagis® (palivizumab) to prevent serious respiratory syncytial virus disease (RSV) in high risk infants and young children. Applicable Procedure Code: 90378.
T Status Codes (CES) – Oxford Reimbursement Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses procedure codes assigned a "T" status indicator on the National Physician Fee Schedule (NPFS) by the Centers for Medicare and Medicaid Services (CMS). Applicable Procedure Codes: 36598, 94760, 94761, 96523, G0117, G0118.
Telehealth and Telemedicine (CES) – Oxford Reimbursement Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses telemedicine and telehealth services.
Temporomandibular Joint Disorders – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20605, 20606, 21010, 21050, 21060, 21085, 21089, 21110, 21240, 21242, 21243, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Tepezza™ (Teprotumumab-Trbw) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Tepezza™ (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Codes: C9399, J3490, J3590.
Thermography – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Time Span Codes – Oxford Reimbursement Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses time span codes.
Timeframe Standards for Utilization Management (UM) Initial Decisions – Oxford Administrative Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses initial utilization management decision and notification timeframes.
Total Artificial Disc Replacement for the Spine – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 03.01.2020 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Transcatheter Heart Valve Procedures – Oxford Clinical Policy
Last Published 05.20.2020
Effective Date: 03.01.2020 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral, tricuspid) procedures, including valve-in-valve procedures and transcatheter cerebral protection devices. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Transcranial Magnetic Stimulation – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Trogarzo® (Ibalizumab-Uiyk) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Trogarzo® (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.
Umbilical Cord Blood Harvesting and Storage for Future Use – Oxford Clinical Policy
Last Published 07.01.2019
Effective Date: 07.01.2019 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Vertebral Body Tethering for Scoliosis – Oxford Clinical Policy
Last Published 03.01.2020
Effective Date: 03.01.2020 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 22899.
Vyepti™ (Eptinezumab-Jjmr) – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of Vyepti™ (Eptinezumab) for the treatment of chronic and episodic migraine. Applicable Procedure Codes: C9399, J3490, J3590.
Vyondys 53™ (Golodirsen) – Oxford Clinical Policy
Last Published 04.01.2020
Effective Date: 04.01.2020 – This policy addresses the use of Vyondys 53™ (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Codes: C9399, J3490, J3590.
White Blood Cell Colony Stimulating Factors – Oxford Clinical Policy
Last Published 05.01.2020
Effective Date: 05.01.2020 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Udenyca, Zarxio, and Ziextenzo. Applicable Procedure Codes: C9058, J1442, J1447, J2505, J2820, J3490, J3590, Q5101, Q5108, Q5110, Q5111.
Whole Exome and Whole Genome Sequencing – Oxford Clinical Policy
Last Published 09.01.2019
Effective Date: 09.01.2019 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 81415, 81416, 81417, 81425, 81426, 81427.
Zolgensma® (Onasemnogene Abeparvovec-Xioi) – Oxford Clinical Policy
Last Published 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Codes: C9399, J3490, J3590.
Zulresso™ (Brexanolone) – Oxford Clinical Policy
Last Published 02.12.2020
Effective Date: 01.01.2020 – This policy addresses the use of Zulresso™ (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Codes: C9055, J3490, J3590.
Information regarding a policy or procedure that is not available online and copies of UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies can also be obtained by sending a written request to:
Oxford Policy Requests
4 Research Drive
Shelton, CT 06484
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.