| Policy Title |
Policy Number |
Status |
Effective Date |
Retire Date |
| Acupuncture (PDF) |
CP.MP.92 |
Retired |
May 1, 2024 |
August 1, 2025 |
| Alternative or Complementary Healing (PDF) |
QCP.CP.018 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Ambulance Services (PDF) |
QCP.CP.045 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Autism Spectrum Disorder Treatment (PDF) |
QCP.CP.044 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Back Brace |
QCP.CP.038 |
Retired |
November 1, 2024 |
November 1, 2025 |
| Bariatric Surgery (PDF) |
CP.MP.37 |
Retired |
May 1, 2024 |
January 1, 2026 |
| Bariatric Surgery: Federal Employees Health Benefits (PDF) |
QCP.CP.029 |
Retired |
January 1, 2010 |
January 1, 2026 |
Corneal Remodeling (f.n.a.Refractive Surgical Procedures) (PDF)
|
QCP.CP.021 |
Retired |
September 18, 1995 |
January 1, 2026 |
| Corneal Topography (PDF) |
QCP.CP.022 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Diabetic Orthotics |
QCP.CP.023 |
Retired |
November 1, 2024 |
November 1, 2025 |
| DME (PDF) |
ar.cp.mp.107 |
Retired |
June 1, 2009 |
January 1, 2026 |
| FEHB Fertility Preservation (PDF) |
QCP.CP.042 |
Retired |
January 1, 2023 |
January 1, 2026 |
FEHBP Gender Reassignment Surgery (PDF)
|
QCP.CP.037 |
Retired |
January 1, 2015 |
January 1, 2026 |
| Ferriscan R2-MRI - RETIRE (PDF) |
CP.MP.53 |
Retired |
May 1, 2024 |
October 1, 2024 |
| Habilitative Services (PDF) |
QCP.CP.035 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Home Ventilators (PDF) |
CP.MP.184 |
Retired |
May 1, 2024 |
August 1, 2025 |
| Hypnotherapy (PDF) |
QCP.CP.014 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Intraoperative Neurophysiological Monitoring (PDF) |
QCP.CP.033 |
Retired |
January 1, 2013 |
January 1, 2026 |
| Knee Brace |
QCP.CP.039 |
Retired |
November 1, 2024 |
November 1, 2025 |
Medical Services that Require Dental Services (PDF)
|
QCP.CP.030 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Physician Extenders (PDF) |
QCP.PP.032 |
Retiring |
May 1, 2024 |
April 1, 2026 |
Prosthetics (PDF)
|
QCP.CP.028 |
Retired |
May 1, 2009 |
January 1, 2026 |
| SNF Leveling (PDF) |
CP.MP.206 |
Retired, changed to cc.pp.206 |
May 1, 2024 |
December 1, 2024
|
| Transcatheter Closure of Patent Foramen Ovale (PDF) |
CP.MP.151 |
Retired |
May 1, 2024 |
December 1, 2024 |
| Obesity Management & Bariatric Surgery (PDF) |
QCP.CP.041 |
Retired |
May 1, 2024 |
November 1, 2025 |
| TMJ Coverage (PDF) |
QCP.CP.026 |
Retired |
May 1, 2024 |
November 1, 2025 |
| Infertility Diagnosis and Treatment (PDF) |
QC.CP.015 |
Retired |
May 1, 2024 |
June 1, 2026 |
| Gender Affirming Procedures (PDF) |
CP.MP.95 |
Retired |
May 1, 2024 |
June 15, 2026 |
| Sacroiliac Joint Fusion (PDF) |
CP.MP.126 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Oncology: Algorithmic Testing (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| AR.V1.2025 - CG Oncology: Cancer Screening AR Specific Version (PDF) |
AR.V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Oncology: Cytogenetic Testing (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Aortopathies and Connective Tissue Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Cardiac Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Dermatologic Conditions (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Eye Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Gastroenterologic Disorders Non-Cancerous (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: General Approach to Genetic and Molecular Testing (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Hearing Loss (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Hematologic Conditions Non-Cancerous (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Hereditary Cancer Susceptibility (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Kidney Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Lung Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Prenatal Cell-Free DNA Testing (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Pharmacogenetics (Version B) (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Preimplantation Genetic Testing (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Prenatal and Preconception Carrier Screening (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
| V1.2025 - CG Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF) |
V1.2025 |
Retired |
May 1, 2024 |
June 15, 2026 |
