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Medical Policies - Medical

  • Accelerated Partial Breast Irradiation Medicaid - Medical 207

    PDF, 269 KBLast Updated: 05/12/2025

    PDF, 269 KBLast Updated: 05/12/2025

  • Apixaban (Eliquis) Drug Level Medicaid - Medical 303

    PDF, 235 KBLast Updated: 05/14/2025

    PDF, 235 KBLast Updated: 05/14/2025

  • Autologous Serum Tears Commercial - Medical 244

    PDF, 187 KBLast Updated: 05/14/2025

    PDF, 187 KBLast Updated: 05/14/2025

  • Autologous Serum Tears Medicare - Medical 244

    PDF, 232 KBLast Updated: 05/12/2025

    PDF, 232 KBLast Updated: 05/12/2025

  • Bulking Agents for Vocal Cord Insufficiency Medicaid - Medical 153

    PDF, 265 KBLast Updated: 05/14/2025

    PDF, 265 KBLast Updated: 05/14/2025

  • Chemotherapy and Supportive Care Medicare Medical 316

    PDF, 326 KBLast Updated: 08/01/2025

    PDF, 326 KBLast Updated: 08/01/2025

  • Dry Needling Commercial - Medical 173

    PDF, 251 KBLast Updated: 07/02/2025

    PDF, 251 KBLast Updated: 07/02/2025

  • Electric Cell-Signaling Energy Waves (EcST and ESI) Commercial - Medical 179

    PDF, 150 KBLast Updated: 05/14/2025

    PDF, 150 KBLast Updated: 05/14/2025

  • Enteral and Parenteral Feeding and Intradialytic Parenteral Nutrition Medicaid - Medical 13

    PDF, 327 KBLast Updated: 05/15/2025

    PDF, 327 KBLast Updated: 05/15/2025

  • Eustachian tube balloon dilation (ETBD) Tuboplasty Medicare - Medical 328

    PDF, 324 KBLast Updated: 05/15/2025

    PDF, 324 KBLast Updated: 05/15/2025

  • FF - Long-Term Care Hospital (LTACH) Services s Medicare Medical 337.pdf

    PDF, 311 KBLast Updated: 07/02/2025

    PDF, 311 KBLast Updated: 07/02/2025

  • Gait analysis and surface electromyography Commercial - Medical 345.pdf

    PDF, 232 KBLast Updated: 05/15/2025

    PDF, 232 KBLast Updated: 05/15/2025

  • Gastrointestinal Capsule Endoscopy Medicaid - Medical 81

    PDF, 313 KBLast Updated: 05/14/2025

    PDF, 313 KBLast Updated: 05/14/2025

  • Genetic and Molecular Testing Medicaid Medical 34

    PDF, 351 KBLast Updated: 08/13/2025

    PDF, 351 KBLast Updated: 08/13/2025

  • Genetic and Molecular Testing Commercial Medical 34

    PDF, 335 KBLast Updated: 08/13/2025

    PDF, 335 KBLast Updated: 08/13/2025

  • Implantable Hemodynamic Monitoring for Heart Failure Medicare - Medical 317

    PDF, 262 KBLast Updated: 05/15/2025

    PDF, 262 KBLast Updated: 05/15/2025

  • Infrared Light Therapy and Low-Level Laser Therapy Medicaid - Medical 109

    PDF, 267 KBLast Updated: 05/14/2025

    PDF, 267 KBLast Updated: 05/14/2025

  • Ingestible Devices Commercial - Medical 344

    PDF, 185 KBLast Updated: 05/14/2025

    PDF, 185 KBLast Updated: 05/14/2025

  • Injectable Hormone Pellets Commercial - Medical 157

    PDF, 217 KBLast Updated: 05/14/2025

    PDF, 217 KBLast Updated: 05/14/2025

  • Keratoconus Lenses and Interventions-Piggyback Contact Lenses Commercial - Medical 03

    PDF, 289 KBLast Updated: 06/04/2025

    PDF, 289 KBLast Updated: 06/04/2025

  • Muscle Pain Detector Medicaid - Medical 247

    PDF, 263 KBLast Updated: 05/14/2025

    PDF, 263 KBLast Updated: 05/14/2025

  • Nonemergent Ambulance Services Commercial - Medical 105

    PDF, 294 KBLast Updated: 08/19/2025

    PDF, 294 KBLast Updated: 08/19/2025

  • Physical Therapy for Treating Obesity Commercial - Medical 252

    PDF, 295 KBLast Updated: 05/14/2025

    PDF, 295 KBLast Updated: 05/14/2025

  • Physical Therapy for Treating Obesity Medicaid - Medical 252

    PDF, 297 KBLast Updated: 05/14/2025

    PDF, 297 KBLast Updated: 05/14/2025

  • Physical Therapy for Treating Obesity Medicare - Medical 252

    PDF, 268 KBLast Updated: 05/15/2025

    PDF, 268 KBLast Updated: 05/15/2025

  • Sclerotherapy and Prolotherapy for Joints and Tendons Commercial - Medical 108

    PDF, 190 KBLast Updated: 05/14/2025

    PDF, 190 KBLast Updated: 05/14/2025

  • Sclerotherapy and Prolotherapy for Joints and Tendons Medicaid - Medical 108

    PDF, 217 KBLast Updated: 05/14/2025

    PDF, 217 KBLast Updated: 05/14/2025

  • Transarterial Embolization Direct Therapies (TAE, TACE and DEB-TACE) Commercial - Medical 139

    PDF, 319 KBLast Updated: 05/14/2025

    PDF, 319 KBLast Updated: 05/14/2025

  • Wearable Monitoring and Treatment Devices Commercial Medical 259

    PDF, 279 KBLast Updated: 08/01/2025

    PDF, 279 KBLast Updated: 08/01/2025

  • Wearable Monitoring and Treatment Devices Medicaid Medical 259

    PDF, 283 KBLast Updated: 08/01/2025

    PDF, 283 KBLast Updated: 08/01/2025

  • Wearable Monitoring Devices Commercial Medical 259

    PDF, 274 KBLast Updated: 05/12/2025

    PDF, 274 KBLast Updated: 05/12/2025

  • Wearable Monitoring Devices Medicaid Medical 259

    PDF, 297 KBLast Updated: 05/12/2025

    PDF, 297 KBLast Updated: 05/12/2025

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© Sentara Health Plans 2025, PO Box 66189, Virginia Beach, Virginia 23466

Sentara Health Plans is the trade name for Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., and Sentara Behavioral Health Services, Inc. Vantage Health Maintenance Organization (HMO) and Point of Service (POS) plans are issued and underwritten by Sentara Health Plans. Medicare products are administered under an agreement with Sentara Health Plans and the Centers for Medicare and Medicaid Services (CMS). Medicaid and Family Access to Medical Insurance Security (FAMIS) products are administered under an agreement with Sentara Health Plans and the Virginia Department of Medical Assistance Services (DMAS). Plus Preferred Provider Organization (PPO) products are issued and underwritten by Sentara Health Insurance Company. The Sentara Employee Assistance Program (EAP) is administered by Sentara Behavioral Health Services, Inc. Large group self-funded health plans and BusinessEDGE® plans are administered but not underwritten by Sentara Health Administration, Inc. Wellness programs are administered by Sentara Health Administration, Inc. All plans have benefit exclusions and limitations, and terms under which the policy or plan may be continued in force or discontinued. For costs and complete details of coverage, please call your broker or review this website for more information. Sentara Health Plans complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.