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Medical & Drug Policies

Medical Benefit Coverage Policies (BCP)Drug Determination Policies (DDP)Archived Medical Benefit Coverage Policies (BCP)Archived Drug Determination Policies (DDP)

Archived Medical Benefit Coverage Policies (BCP)

Attention - Physicians Health Plan (PHP) is now University of Michigan Health Plan (UM Health Plan). Documents published before this change may still have references to the PHP brand.
Archived

Archived PHP Medical Benefit Coverage Policies (BCP)

Ambulance Transport

(

BCP-10

)
Effective Date:
1/1/2023

Ambulance Transport

(

BCP-10

)
Effective Date:
1/1/2022

Ambulance Transport

(

BCP-10

)
Effective Date:
1/1/2021

Ambulance Transport

(

BCP-10

)
Effective Date:
1/1/2020

Ambulance Transport

(

BCP-10

)
Effective Date:
1/1/2019

Ambulance Transport

(

BCP-10

)
Effective Date:
4/1/2018

Ambulatory EEG and Video Monitoring

(

BCP-80

)
Effective Date:
1/1/2023

Ambulatory EEG and Video Monitoring

(

BCP-80

)
Effective Date:
1/1/2022

Ambulatory EEG and Video Monitoring

(

BCP-80

)
Effective Date:
10/1/2020

Ambulatory EEG and Video Monitoring

(

BCP-80

)
Effective Date:
8/7/2020

Applied Behavioral Analysis (ABA) Therapy for Treatment of Autism Spectrum Disorders

(

BCP-12

)
Effective Date:
7/1/2023

Applied Behavioral Analysis (ABA) Therapy for Treatment of Autism Spectrum Disorders

(

BCP-12

)
Effective Date:
7/1/2022

Applied Behavioral Analysis (ABA) Therapy for Treatment of Autism Spectrum Disorders

(

BCP-12

)
Effective Date:
7/1/2021

Applied Behavioral Analysis (ABA) Therapy for Treatment of Autism Spectrum Disorders

(

BCP-12

)
Effective Date:
10/1/2020

Applied Behavioral Analysis (ABA) Therapy for Treatment of Autism Spectrum Disorders

(

BCP-12

)
Effective Date:
10/1/2019

Bariatric Surgery

(

BCP-32

)
Effective Date:
7/1/2022

Bariatric Surgery

(

BCP-32

)
Effective Date:
7/1/2021

Bariatric Surgery

(

BCP-32

)
Effective Date:
10/1/2020

Bariatric Surgery

(

BCP-32

)
Effective Date:
10/1/2019

Bariatric Surgery

(

BCP-32

)
Effective Date:
7/1/2018

CAR T-Cell Immunotherapy

(

BCP-77

)
Effective Date:
10/1/2018

COVID-19 Testing and Treatment

(

BCP-15

)
Effective Date:
1/1/2023

COVID-19 Testing and Treatment

(

BCP-15

)
Effective Date:
10/1/2021

COVID-19 Testing and Treatment

(

BCP-15

)
Effective Date:
3/20/2020

Cardiac Transplantation

(

BCP-66

)
Effective Date:
4/1/2023

Cardiac Transplantation

(

BCP-66

)
Effective Date:
4/1/2022

Cardiac Transplantation

(

BCP-66

)
Effective Date:
4/1/2021

Complementary and Alternative Medicine (CAM)

(

BCP-29

)
Effective Date:
10/1/2022

Complementary and Alternative Medicine (CAM)

(

BCP-29

)
Effective Date:
10/1/2021

Complementary and Alternative Medicine (CAM)

(

BCP-29

)
Effective Date:
8/7/2020

Complementary and Alternative Medicine (CAM)

(

BCP-29

)
Effective Date:
7/1/2020

Complementary and Alternative Medicine (CAM)

(

BCP-29

)
Effective Date:
1/1/2020

Continuous Glucose Monitors

(

BCP-64

)
Effective Date:
1/1/2021

Continuous Glucose Monitors

(

BCP-64

)
Effective Date:
1/1/2020

Continuous Glucose Monitors

(

BCP-64

)
Effective Date:
1/1/2019

Continuous Glucose Monitors

(

BCP-64

)
Effective Date:
4/1/2018

Continuous Glucose Monitors and Supplies

(

BCP-64

)
Effective Date:
1/1/2023

Continuous Glucose Monitors and Supplies

(

BCP-64

)
Effective Date:
1/1/2022

Dental Services Requiring General Anesthesia

(

BCP-16

)
Effective Date:
4/1/2018

Dental-Related General Anesthesia

(

BCP-16

)
Effective Date:
1/1/2019

Dental-Related General Anesthesia and Facility Charges

(

BCP-16

)
Effective Date:
4/1/2023

Dental-Related General Anesthesia and Facility Charges

(

BCP-16

)
Effective Date:
4/1/2022

Dental-Related General Anesthesia and Facility Charges

(

BCP-16

)
Effective Date:
4/1/2021

Dental-Related General Anesthesia and Facility Charges

(

BCP-16

)
Effective Date:
4/1/2020

Drug Testing in Pain Management and Substance Use Disorders Treatment

(

BCP-78

)
Effective Date:
10/1/2022

Drug Testing in Pain Management and Substance Use Disorders Treatment

(

BCP-78

)
Effective Date:
10/1/2021

Drug Testing in Pain Management and Substance Use Disorders Treatment

(

BCP-78

)
Effective Date:
1/1/2020

Drug Testing in Pain Management and Substance Use Disorders Treatment

(

BCP-78

)
Effective Date:
9/3/2019

Drug Testing in Pain Management and Substance Use Disorders Treatment

(

BCP-78

)
Effective Date:
1/1/2019

Facet Join Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
8/7/2020

Facet Join Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
7/1/2020

Facet Join Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
10/1/2019

Facet Joint Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
4/1/2023

Facet Joint Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
4/1/2022

Facet Joint Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
1/1/2022

Facet Joint Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
7/1/2021

Facet Joint Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
1/1/2019

Fecal Bacteriotherapy

(

BCP-69

)
Effective Date:
1/1/2023

Fecal Bacteriotherapy

(

BCP-69

)
Effective Date:
1/1/2022

Fecal Bacteriotherapy

(

BCP-69

)
Effective Date:
1/1/2021

Fecal Bacteriotherapy

(

BCP-69

)
Effective Date:
1/1/2020

Fecal Bacteriotherapy

(

BCP-69

)
Effective Date:
10/1/2018

Femoro-Acetabular Impingement Hip Surgery

(

BCP-65

)
Effective Date:
1/1/2023

Femoro-Acetabular Impingement Hip Surgery

(

BCP-65

)
Effective Date:
1/1/2022

Femoro-Acetabular Impingement Hip Surgery

(

BCP-65

)
Effective Date:
1/1/2020

Femoro-Acetabular Impingement Hip Surgery

(

BCP-65

)
Effective Date:
1/1/2019

Femoro-Acetabular Impingement Hip Surgery

(

BCP-65

)
Effective Date:
4/1/2018

Gender Reassignment Surgery

(

BCP-24

)
Effective Date:
1/1/2022

Gender Reassignment Surgery

(

BCP-24

)
Effective Date:
1/1/2021

Gender Reassignment Surgery

(

BCP-24

)
Effective Date:
1/1/2019

Gender Reassignment Surgery

(

BCP-24

)
Effective Date:
4/1/2018

Glaucoma Surgery iStent Trabecular Micro-Bypass Stent

(

BCP-68

)
Effective Date:
4/1/2021

Glaucoma Surgery iStent Trabecular Micro-Bypass Stent

(

BCP-68

)
Effective Date:
1/1/2020

Glaucoma Surgery iStent Trabecular Micro-Bypass Stent

(

BCP-68

)
Effective Date:
7/1/2018

Hearing Aids and Services

(

BCP-21

)
Effective Date:
10/1/2022

Hearing Aids and Services

(

BCP-21

)
Effective Date:
10/1/2021

Hearing Aids and Services

(

BCP-21

)
Effective Date:
8/7/2020

Hearing Aids and Services

(

BCP-21

)
Effective Date:
1/1/2020

Heart Transplantation

(

BCP-66

)
Effective Date:
1/1/2020

Heart Transplantation

(

BCP-66

)
Effective Date:
10/1/2019

Heart Transplantation

(

BCP-66

)
Effective Date:
4/1/2018

Hematopoietic Stem Cell Transplant

(

BCP-67

)
Effective Date:
7/1/2022

Hematopoietic Stem Cell Transplant

(

BCP-67

)
Effective Date:
7/1/2021

Hematopoietic Stem Cell Transplant

(

BCP-67

)
Effective Date:
10/1/2020

Hematopoietic Stem Cell Transplant

(

BCP-67

)
Effective Date:
10/1/2019

Hematopoietic Stem Cell Transplant

(

BCP-67

)
Effective Date:
7/1/2018

Home Health Care Services

(

BCP-26

)
Effective Date:
1/1/2023

Home Health Care Services

(

BCP-26

)
Effective Date:
1/1/2022

Home Health Care Services

(

BCP-26

)
Effective Date:
10/1/2020

Home Health Care Services

(

BCP-26

)
Effective Date:
10/1/2019

Home Infusion Therapy Services

(

BCP-27

)
Effective Date:
10/1/2022

Home Infusion Therapy Services

(

BCP-27

)
Effective Date:
10/1/2021

Home Infusion Therapy Services

(

BCP-27

)
Effective Date:
10/1/2020

Home Infusion Therapy Services

(

BCP-27

)
Effective Date:
10/1/2019

Hospice Care Services

(

BCP-22

)
Effective Date:
1/1/2023

Hospice Care Services

(

BCP-22

)
Effective Date:
10/1/2022

Hospice Care Services

(

BCP-22

)
Effective Date:
10/1/2021

Hospice Care Services

(

BCP-22

)
Effective Date:
10/1/2020

Hospice Care Services

(

BCP-22

)
Effective Date:
1/1/2020

Hospice Care Services

(

BCP-22

)
Effective Date:
4/1/2018
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