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Archived Policies

Clinical Policies
Policy NumberPolicy TitleEffective Date StartRetire Date
CP.MP.151Transcatheter Closure of Patent Foramen Ovale (PDF)March 1, 2019December 1, 2024
CP.MP.206SNF Leveling (PDF)March 1, 2019December 1, 2024
CP.MP.53Ferriscan R2-MRI (PDF)March 1, 2019October 1, 2024
cp.mp.184Home ventilators (PDF)March 1, 2019August 1, 2025
CP.MP.92Acupuncture (PDF)March 1, 2019August 1, 2025
Pharmacy Policies
Policy NumberPolicy TitleEffective Date StartRetire Date
    
    
    
    
Payment Policies
Policy NumberPolicy TitleEffective Date StartRetire Date