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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements
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Payment Policies

Medical Policies
Medical policies are available below for review. Please check back periodically for updates or refer to the archive of Medical Policy Updates for additional information. 
Policy Title 


Allergy Immunotherapy

Allergy Testing

Audiological Testing, Vestibular Function Testing, and Related Services

Autologous Chondrocyte Transplantation

Automated Ambulatory Blood Pressure Monitor


Bone Density Studies

Botulinum Toxin Therapy

Cardiac Rehabilitation


Cochlear Implantation and Related Services


Continuous Passive Motion (CPM) Device

Critical and/or Intensive Care Services

Deep Brain Stimulation

Diagnostic medpol_radiol_Surgical Introductory Procedures (SIPs)

Electrical Bone Growth Stimulation

Herceptin (Trastuzumab)

Home Apnea Monitor

Home Phototherapy for Neonatal Jaundice

Home Uterine Activity Monitoring (HUAM)

Hybrid Capture Human Papillomavirus (HPV) DNA Assay

Immune Prophylaxis for Respiratory Syncytial Virus

Immunizations: Child and Adult

Laser Treatment of Congenital Port Wine Stain and Hemangiomas

Lupron (Leuprolide)

Lymphedema Therapy: Treatment and Supplies

Manipulation Services

Mifepristone (RU 486)

Mohs' Micrographic Surgery

Monoclonal Antibody Agents

Myoelectrical Prosthesis (MP)

Nasal/Sinus Endoscopy

Non-Invasive Vascular Studies

Obesity Guidelines

On-Line Evaluation and Management Services (Telemedicine)

Penile Prostheses

Phototherapy Light for the Treatment of Seasonal Affective Disorder (SAD)

Podiatric Services

Prenatal Diagnosis for Genetic Disease

Preventive Medicine Services: Annual Physical Exams and Diagnostic Screening

Prostate Screening

Prostate Surgery

Pulmonary Rehabilitation

Reduction Mammaplasty


Rhinoplasty and Submucous Resection


Trigger Point Injections

Ultrasonic Bone Growth Stimulation

Urodynamic Studies

Virtual Colonoscopy

Payment Policies
Stay current on Empire's payment policies by clicking on the PDFs below. 

Reimbursement Policies

Claim Reimbursement Policies for Common Services

Empire Adopts CMS Code Edits into Its Payment Policy

Empire's HMO & PPO Physician Office Lab (POL) List

Empire Adopts Medical Policies Consistent with CMS

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