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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-134 Prenatal and Postpartum Services Cost-Sharing Waiver

Starting January 1, 2025, a new NY State of Health (NYSOH) program under New York’s Section 1332 waiver will enhance access and affordability for pregnant and postpartum Qualified Health Plan (QHP) members.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-132 Obstetric Billing Guidelines

This policy describes the reimbursement of global obstetrical (OB) codes and the itemization of maternity care services. Maternity care encompasses prenatal, delivery, antepartum, and postpartum care.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-015 Testing for Vector Borne Infections

Arthropod vectors, including mosquitoes, ticks, fleas, and mites, that feed on vertebrate hosts can spread bacteria, protozoa, and viruses during feeding to their susceptible host, resulting in a variety of infections and diseases.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-125 Serum Testing for Evidence of Mild Traumatic Brain Injury

Traumatic brain injury (TBI) is characterized by pathologic injuries to the brain resulting from external forces or trauma.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-064 Immunopharmacologic Monitoring of Therapeutic Serum Antibodies

To manage loss of response due to the development of anti-drug antibodies, immunopharmacologic monitoring of circulating drug and anti-drug antibody levels has been proposed. The presence of anti-drug antibodies may promote adverse effects and diminish drug efficacy (Bendtzen, 2024; Tighe & McNamara, 2017).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-063 General Inflammation Testing

Inflammatory response can occur due to tissue injury and/or various disorders, including arthritis, lupus, and infection. Acute phase reactants, such as serum C-reactive protein (CRP), are released in the acute phase response during inflammation and can be used to monitor inflammation.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-061 Serum Biomarker Testing for Multiple Sclerosis and Related Neurological Diseases

Multiple sclerosis (MS) is the most common immune-mediated inflammatory demyelinating disease of the central nervous system (CNS) and is defined by multifocal areas of demyelination with loss of oligodendrocytes and astroglial scarring.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-058 Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a class of inflammatory bowel disorders comprised of two major disorders: ulcerative colitis and Crohn’s disease each with distinct pathologic and clinical characteristics (Peppercorn & Cheifetz, 2024).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-057 Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

Chronic liver disease (CLD) refers to a wide range of liver pathologies that include inflammation (chronic hepatitis), liver cirrhosis, and hepatocellular carcinoma.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-056 Gamma-glutamyl Transferase

Gamma-glutamyl transferase (GGT), also known as gamma-glutamyl transpeptidase (GGTP) (Singh et al., 2006; Vroon & Israili, 1990), is an enzyme that has a half-life of between fourteen and twenty-six days and is present in the cell membrane of many different tissue types, including the heart, brain, seminal vesicles, kidneys, bile duct, spleen, and gallbladder (Dillon & Miller, 2016; Dixit & Singh, 2015).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-055 Pancreatic Enzyme Testing for Acute Pancreatitis

Pancreatitis is an inflammation of pancreatic tissue and can be either acute or chronic. Pancreatic enzymes, including amylase, lipase, and trypsinogen can be used to monitor the relative health of the pancreatic tissue.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-054 Fecal Calprotectin Testing in Adults

Calprotectin is a small calcium-binding protein found in high concentration in the cytosol of neutrophils (Fagerhol et al., 1980) and to a lesser extent monocytes and macrophages (Hsu et al., 2009).

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