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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)

Medical Benefit Coverage Policies (BCP)

Please check back often as we add new Medical Policies and edit existing Medical Policies on a regular basis.

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.

Current PHP Medical Benefit Coverage Policies (BCP)

Ambulance Transport

(

BCP-10

)
Effective Date:
1/1/2024

Ambulatory EEG and Video Monitoring

(

BCP-80

)
Effective Date:
1/1/2024

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

(

BCP-12

)
Effective Date:
7/1/2023

Bariatric Surgery

(

BCP-32

)
Effective Date:
7/1/2023

COVID-19 Testing and Treatment

(

BCP-15

)
Effective Date:
5/11/2023

Cardiac Transplantation

(

BCP-66

)
Effective Date:
4/1/2024

Clinical Trials

(

BCP-83

)
Effective Date:
4/1/2024

Complementary and Alternative Medicine (CAM)

(

BCP-29

)
Effective Date:
10/1/2023

Continuous Glucose Monitors and Supplies

(

BCP-64

)
Effective Date:
1/1/2024

Continuous Passive Motion (CPM) Machine

(

BCP-82

)
Effective Date:
10/1/2023

Dental-Related General Anesthesia and Facility Charges

(

BCP-16

)
Effective Date:
4/1/2024

Drug Testing in Pain Management and Substance Use Disorders Treatment

(

BCP-78

)
Effective Date:
10/1/2023

Facet Joint Injections and Facet Neurotomy for Pain Management

(

BCP-74

)
Effective Date:
4/1/2024

Fecal Bacteriotherapy

(

BCP-69

)
Effective Date:
1/1/2024

Femoro-Acetabular Impingement Hip Surgery

(

BCP-65

)
Effective Date:
1/1/2024

Gender Reassignment Surgery

(

BCP-24

)
Effective Date:
1/1/2023

Glaucoma Surgery iStent Trabecular Micro-Bypass Stent

(

BCP-68

)
Effective Date:
7/1/2023

Greater Occipital Nerve Block

(

BCP-84

)
Effective Date:
7/1/2024

Hearing Aids and Services

(

BCP-21

)
Effective Date:
10/1/2023

Hematopoietic Stem Cell Transplant

(

BCP-67

)
Effective Date:
7/1/2023

Home Health Care Services

(

BCP-26

)
Effective Date:
1/1/2024

Home Infusion Therapy Services

(

BCP-27

)
Effective Date:
10/1/2023

Hospice Care Services

(

BCP-22

)
Effective Date:
1/1/2024

Infertility Services

(

BCP-72

)
Effective Date:
1/1/2024

Inpatient Rehabilitation (IPR) Services

(

BCP-23

)
Effective Date:
10/1/2023

Liver Transplantation

(

BCP-75 v.7

)
Effective Date:
4/1/2024

Lung Transplantation

(

BCP-70

)
Effective Date:
7/1/2024

Observation Care Services

(

BCP-04

)
Effective Date:
1/1/2024

Orthognathic Surgery

(

BCP-36

)
Effective Date:
4/1/2024

Outpatient Cardiac Rehabilitation Therapy Services

(

BCP-08

)
Effective Date:
1/1/2024

Outpatient High Tech Radiology and Nuclear Medicine

(

BCP-39

)
Effective Date:
1/1/2024

Outpatient Pulmonary Rehabilitation Therapy Services

(

BCP-07

)
Effective Date:
4/1/2024

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
7/1/2023

Outpatient Rehabilitative-Habilitative Services-Physical and Occupational Therapy

(

BCP-06

)
Effective Date:
4/11/2023

Pancreas Transplantation

(

BCP-71 v.7

)
Effective Date:
4/1/2024

Pre-Transplant Services

(

BCP-33

)
Effective Date:
1/1/2024

Preventive Health Services

(

BCP-45

)
Effective Date:
1/1/2023

Renal Transplantation

(

BCP-51 v.8

)
Effective Date:
4/1/2024

Repair of Brow Ptosis

(

BCP-76

)
Effective Date:
7/1/2023

Retransplantation and Pediatric Transplantation

(

BCP-17 v.4

)
Effective Date:
4/1/2024

Sacral Nerve Stimulation for Urinary and Fecal Incontinence

(

BCP-81

)
Effective Date:
7/1/2024

Spinal Cord Stimulation for Pain Management

(

BCP-73

)
Effective Date:
7/1/2024

Sub-Acute Rehabilitation (SAR) Services in a Skilled Nursing Facility (SNF)

(

BCP-61

)
Effective Date:
10/1/2023

Telemedicine Services

(

BCP-50

)
Effective Date:
7/1/2023

Therapeutic Shoes and Inserts for Diabetic Patients

(

BCP-03

)
Effective Date:
1/1/2024

Varicose Vein Treatment

(

BCP-63

)
Effective Date:
1/1/2024

Weight Management Services

(

BCP-60

)
Effective Date:
7/1/2023
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