Virginia Premier has developed medical policies that serve as guidelines for coverage decisions and assist with administering plan benefits. The policies express Virginia Premier’s determination of whether certain services are medically necessary, and they are based upon a review of currently available clinical information. These peer-reviewed policies are used when no specific guidelines for coverage are provided by the Department of Medical Assistance Services of Virginia (DMAS) or by the Center for Medicare and Medicaid Services (CMS). Medical policies are not a substitute for clinical judgment or for any prior authorization requirements of the health plan. These policies are not an explanation of benefits.
Medical policies can be highly technical and complex and are provided here for informational purposes. These medical policies are intended for use by health care professionals. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Virginia Premier members should discuss the information in the medical policies with their treating health care professionals.
Medical technology is constantly evolving and these medical policies are subject to change without notice, although Virginia Premier will notify providers as required in advance of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use. Medical policies that have become obsolete will be archived as appropriate. The medical policies generally apply to all Virginia Premier’s plans, although some variations may exist by plan type. Members may contact customer services representatives for specific coverage information.
Medicaid & Medicare Codes
Medical Policies
- Abdominoplasty, Lipectomy, and Panniculectomy
- Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
- Adakveo (Crizanlizumab)
- Adoptive Immunotherapy and Cellular Therapy
- Adulhelm
- Anesthesia Services and Moderate Conscious Sedation
- Anesthesia Services for Gastrointestinal Endoscopic Procedures
- Anti-Emetic Medications
- Apheresis (Plasmapheresis, Plasma Exchange, Lipid Pheresis and Protein A Column Pheresis)
- Autologous Platelet-Rich Plasma
- Biofeedback
- Botox
- CAR-T Therapy
- Category III Codes
- Cervical and Thoracic Discography
- Computer Assisted Navigation for Orthopedic, Spinal, and Cranial Procedures
- Corneal Hysteresis
- COVID Antibody Testing
- Cranial Orthotic Device
- Crysvita (Burosumab-TWZA)
- Diagnostic Genetic Testing of a Potentially Affected Patient
- Dry Needling for the Management of Chronic Low Back Pain
- Exhaled Breath Testing
- Facet Joint Allograft Implants for Facet Disease
- Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
- First Trimester Screening for Aneuploidy
- Gait Analysis
- Gender Affirming Surgery
- Gene-Based Therapy for Duchenne Muscular Dystrophy
- Genicular Nerve Block
- Hematopoietic Stem Cell Transplantation for Diabetes
- Home Phototherapy Devices for Neonatal Hyperbilirubinemia
- Infant Home Apnea Monitors
- Intensity Modulated Radiation Therapy
- Intravenous Iron for the Treatment of Iron Deficiency Anemia in Adults without Chronic Kidney Disease
- IVIG
- IVIG as a Treatment for Recurrent Spontaneous Abortions
- Abdominoplasty, Lipectomy, and Panniculectomy
- Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
- Adakveo (Crizanlizumab)
- Adoptive Immunotherapy and Cellular Therapy
- Adulhelm
- Anesthesia Services and Moderate Conscious Sedation
- Anesthesia Services for Gastrointestinal Endoscopic Procedures
- Anti-Emetic Medications
- Apheresis (Plasmapheresis, Plasma Exchange, Lipid Pheresis and Protein A Column Pheresis)
- Autologous Platelet-Rich Plasma
- Biofeedback
- Botox
- CAR-T Therapy
- Category III Codes
- Cervical and Thoracic Discography
- Computer Assisted Navigation for Orthopedic, Spinal, and Cranial Procedures
- Corneal Hysteresis
- COVID Antibody Testing
- Cranial Orthotic Device
- Crysvita (Burosumab-TWZA)
- Diagnostic Genetic Testing of a Potentially Affected Patient
- Dry Needling for the Management of Chronic Low Back Pain
- Exhaled Breath Testing
- Facet Joint Allograft Implants for Facet Disease
- Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
- First Trimester Screening for Aneuploidy
- Gait Analysis
- Gender Affirming Surgery
- Gene-Based Therapy for Duchenne Muscular Dystrophy
- Genicular Nerve Block
- Hematopoietic Stem Cell Transplantation for Diabetes
- Home Phototherapy Devices for Neonatal Hyperbilirubinemia
- Infant Home Apnea Monitors
- Intensity Modulated Radiation Therapy
- Intravenous Iron for the Treatment of Iron Deficiency Anemia in Adults without Chronic Kidney Disease
- IVIG
- IVIG as a Treatment for Recurrent Spontaneous Abortions
- Laproscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids
- Long Term Acute Care Hospital
- Nasal Surgery for the treatment of Obstructive Sleep Apnea and Snoring
- Nasal Valve Suspension
- Neural Therapy
- Neuromuscular Electrical Stimulators and Functional Electrical Stimulators
- Nucala (Mepolizumab)
- Pamidronate Disodium (Aredia) Injection
- Patient Operated Spinal Unloading Devices
- Phototherapy for Dermatological Indications
- Predictive Genetic Testing for Non-Malignant Disease
- Presbyopia and Astigmatism-Correcting Intraocular Lenses
- Quantitative Muscle Testing Devices
- Real-Time Remote Heart Monitor
- Rhinomanometry and Acoustic Rhinometry
- Skilled Therapies
- Skin Substitutes
- Stretching Devices
- Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes
- Treatment of Congenital Nasolacrimal Obstruction
- Ultrasound for the Evaluation of Paranasal Sinuses
- Ultraviolet Light Therapy Delivery Devices for Home Use
- Vascular Endothelial Growth Factor Inhibitors for Ocular Indications
- Vertebral Body Stapling for Scoliosis in Children and Adolescents
- Vestibular Function Testing
- Vyvgart
- Zolgensma (Onasemnogene Abeparvovec-XIOI) for the Treatment of Spinal Muscular Atrophy