Geisinger Health Plan® - Medical Benefit Policies

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Medical Benefit Policies


Listed below are the recent changes made to policies within the Geisinger Health Plan Medical Policy Portfolio effective January 1, 2012 (unless otherwise specified). The Plan uses medical policies as guidelines for coverage decisions made within the insured individuals written benefit documents. Coverage may vary by line of business and providers and members are encouraged to verify benefit questions regarding eligibility before applying the terms of the policy. This section has been included for you convenience.

Medical Policy Description
MP60 Lung Volume Reduction Surgery (REVISED) Continues to require prior authorization. Added clarification on requirement for surgery to be performed in an approved Center of Excellence as listed by CMS.
MP53 Cochlear Implant (REVISED) Clarified criteria to apply to unilateral or bilateral cochlear implant
MP231 Facet Joint Denervation (NEW) Revised to include information on both radiofrequency (thermal) and neurolytic agent denervation
MBP 76.0 Actemra® (REVISED) Continues to require prior authorization. Revised criteria to include both adult rheumatoid arthritis and active systemic juvenile idiopathic arthritis

The following medical/pharmaceutical policies have been reviewed with no change to the policy section. Additional references or background information
was added to support the current policy.


MP 77 - Non-invasive Mechanical Treatments for Low Back Pain  
MP 186 - Hip Resurfacing Arthroplasty  
MP 210 - Endometrial Ablation  
MP 224 - Topical Oxygenation  
MP 123 - HDR Temporary Brachytherapy for Treatment of Prostate Cancer  
MP 247 - Enteral Nutrition  
MP225 - Circulating Tumor Cell Testing  
MP205 - Advanced Molecular Topographic Genotyping  
MP230 - Outpatient Pulmonary Rehabilitation  
MP81 - Chelation Therapy  
MP108 - Work Hardening, Work Conditioning Programs, and Functional Capacity Exams  
MP191 - Computerized Cognitive Health Assessment Systems