Review ConnectiCare's policies on various medical treatments and emerging medical technologies.
Please note, by downloading or viewing any of the criteria below, you have agreed to accept ConnectiCare's preauthorization criteria user agreement.
Services That Require Preauthorization
View EmblemHealth Medical Policies
In addition to the medical coverage policies listed below, the following resources are used to make medical necessity determinations.
| Policy Name | Download (PDF) |
|---|---|
| Abdominoplasty-Panniculectomy | Download (PDF) |
| Ambulance | Download (PDF) |
| Ambulatory Monitoring Electroencephalogram (EEG) | Download (PDF) |
| Amniotic Membrane Transplantation for Ocular Reconstruction | Download (PDF) |
| Arthroscopy-Arthroplasty | Download (PDF) |
| Autologous Chondrocyte Implantation | Download (PDF) |
| Automatic External Defibrillators | Download (PDF) |
| Balloon Sinuplasty | Download (PDF) |
| Bariatric Surgery | Download (PDF) |
| Biomagnetic Therapy | Download (PDF) |
| Blepharoplasty | Download (PDF) |
| Bone Mineral Density Studies in Adult Populations | Download (PDF) |
| Breast Implants and Reconstruction | Download (PDF) |
| Capsule Endoscopy | Download (PDF) |
| Cardiac Event Monitoring | Download (PDF) |
| Cartilage Implants | Download (PDF) |
| Chemical Peels | Download (PDF) |
| Clinical Trial | Download (PDF) |
| Cochlear Implants | Download (PDF) |
| Congenital Heart Disease | Download (PDF) |
| Continuous Passive Motion Devices | Download (PDF) |
| Cortical Stimulation for Epilepsy (NeuroPace®) | Download (PDF) |
| Cosmetic and Reconstructive Surgery Procedures | Download (PDF) |
| Craniofacial Procedures | Download (PDF) |
| Cryosurgery for Liver Tumors | Download (PDF) |
| Cryosurgical Ablation for Prostate Cancer | Download (PDF) |
| Cryosurgical and Radiofrequency Ablation for Renal Tumors | Download (PDF) |
| Deep Brain Stimulation | Download (PDF) |
| Dermabrasion | Download (PDF) |
| Durable Medical Equipment | Download (PDF) |
| Experimental Investigational or Unproved Services Policy | Download (PDF) |
| External Counterpulsation | Download (PDF) |
| Fecal Microbiota Transplant (FMT) | Download (PDF) |
| Formula and Enteral Nutrition-CT | Download (PDF) |
| Formula and Enteral Nutrition-MA | Download (PDF) |
| gammaCore Sapphire CV Coronavirus | Download (PDF) |
| Gastric Electrical Stimulation | Download (PDF) |
| Gender Affirming Reassignment Surgery | Download (PDF) |
| Glaucoma Surgery | Download (PDF) |
| Gynecomastia | Download (PDF) |
| High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive Ventilators | Download (PDF) |
| Home Health Aide | Download (PDF) |
| Homecare | Download (PDF) |
| Hysterectomy | Download (PDF) |
| Idiopathic Environmental Intolerance | Download (PDF) |
| Infertility | Download (PDF) |
| Insulin Delivery Devices & CGM Systems | Download (PDF) |
| Intrastromal Corneal Ring Segments | Download (PDF) |
| Lyme Disease Diagnosis & Treatment | Download (PDF) |
| Lymphedema Treatment | Download (PDF) |
| Mechanical Stretching Devices | Download (PDF) |
| Neuropsychological Testing | Download (PDF) |
| Non-Invasive Electroencephalogram (EEG) | Download (PDF) |
Non-Invasive H-Pylori Testing
|
Download (PDF) |
| Non-Invasive Prenatal Testing (NIPT) for Fetal Aneuploidy | Download (PDF) |
| Obstructive Sleep Apnea Diagnosis and Treatment | Download (PDF) |
| Ocular Photoscreening Policy | Download (PDF) |
Omnibus Policy
|
Download (PDF) |
| Oral Surgery | Download (PDF) |
| Orthognathic Surgery | Download (PDF) |
| Osteochondral Grafting |
Download (PDF) |
| Osteogenic Stimulators – Non-Spinal Applications | Download (PDF) |
| Osteogenic Stimulators – Spinal Applications | Download (PDF) |
| Osteogenic Stimulators – Ultrasound, Non-invasive | Download (PDF) |
| Osteopathic Manipulative Treatment Policy | Download (PDF) |
| Otoacoustic Emissions Testing Policy | Download (PDF) |
| Penile Implants | Download (PDF) |
| Peripheral Nerve Block | Download (PDF) |
| Periurethral Bulking Agents for Urinary Incontinence | Download (PDF) |
| Phototherapy Photochemotherapy Photodynamic Therapy | Download (PDF) |
| Posterior Tibial Nerve Stimulation for Voiding Dysfunction | Download (PDF) |
| Power Mobility Device | Download (PDF) |
| Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions | Download (PDF) |
| Radiofrequency Ablation of Barrett's Esophagus | Download (PDF) |
| Radiofrequency Ablation for Tumors | Download (PDF) |
| Reduction Mammoplasty | Download (PDF) |
| Rhinoplasty | Download (PDF) |
| Septoplasty | Download (PDF) |
| Site of Service Policy | Download (PDF) |
| Stimulators (Neurostimulation) | Download (PDF) |
| Surgical Correction Chest Wall Deformities | Download (PDF) |
| Sympathectomy for Hyperhidrosis | Download (PDF) |
| TelemedicinePolicy_Updated_2017 | Download (PDF) |
| Tonsillectomy-Adenoidectomy | Download (PDF) |
| Total Ankle Replacement | Download (PDF) |
| Transcatheter Aortic Valve Replacement | Download (PDF) |
| Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence | Download (PDF) |
| Vacuum-Assisted Wound Closure | Download (PDF) |
| Varicose Vein Treatment - effective 11.1.2019 | Download (PDF) |
| Ventricular Assist Device | Download (PDF) |
| Vertical Expandable Prosthetic Titanium Rib (VEPTR) | Download (PDF) |
Vitamin D Deficiency Testing
|
Download (PDF) |
| Visual Electrophysiology Testing | Download (PDF) |
