Medical policies and criteria: new, updated and reviewed
As Security Health Plan reviews and develops clinical criteria on Medical and Interpretation Policies, we ask providers with particular professional knowledge or clinical expertise on certain subjects for their input and opinions. Requests from providers must be documented on the Provider Input Form. Please download and complete the form, then email the completed form to shp.health.services@securityhealth.org. We appreciate your input.
To receive payment, providers must meet all policy criteria outlined for the specific service provided. Please review the below list of medical policies and request a copy of the policies for any procedures you perform in your office.
Security Health Plan medical policies are updated monthly. To review the medical policy changes click here.
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A-D
- Abdominoplasty and Panniculectomy
-
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
Abnormal Vascular Lesion Removal
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Ambulance: Land and Air Transportation
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Autologous Cultured Chondrocytes
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Back Surgical Procedures: Cervical and Thoracic Spinal Levels Inpatient and Outpatient Settings
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Back Surgical Procedures Lumbar Spinal Level Inpatient and Outpatient Settings
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Back Surgical Procedure Vertebroplasty Inpatient and Outpatient Settings
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Biofeedback for Physical Conditions
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Bone and Tendon Graft Substitutes and Adjuncts
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Bone Growth Stimulator for the 5th Metatarsal
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Botulinum Toxin Injections
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
-
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Breast Reduction Mammoplasty
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Cardiomems
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Carpal Tunnel Repair Surgical Precertification
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Cellular Therapies
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Chelation Therapy
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Cochlear Implant
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Cologuard DNA Stool Testing
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Complementary and Alternative Medicine
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Contact Lenses and Other Eyewear
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Core Decompression of AVN of the Femoral Head
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Cosmetic Surgery/Treatments
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Cryoablation
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
E-H
- Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Electroconvulsive Therapy
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Electroencephalography EEG Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Erectile Dysfunction Treatments
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Experimental or Investigational
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Eyelid & Brow Repair
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Eye Movement Desensitization and Reprocessing (EMDR)
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Femoroacetabular Surgery for Hip Impingement Syndrome
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Gamifant
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Gastric Pacing and Gastric Electrical Stimulation
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Gender Reassignment Services and Surgical Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Genetic Testing
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Genetic Testing for Hereditary Cancer
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Genetic Testing for Prenatal and Preconception Carrier Screening
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Genetic Testing for Prenatal Diagnosis (Via Amniocentesis or CVS) and Pregnancy Loss
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Genetic Testing: Non-invasive Prenatal Screening (NIPS)/Non-invasive Prenatal Testing (NIPT
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Genetic Testing Oncology: Cancer Screening
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Home Care Coverage Criteria
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Home Health Care- Medicare Advantage
This policy is required for:
- Medicare Advantage HMO-POS
- Medicare Advantage HMO-POS
- Home Infusion
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Hospice Health Services
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Hyaluronic Acid Derivatives
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Hyperbaric Oxygen Therapy
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Hyperthermic Intraperitoneal Chemotherapy
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Hypoglossal Nerve Neurostimulation
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Hysterectomy Surgical Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
I-L
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
This policy is required for:
- Medicare Advantage HMO-POS
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
M-P
- MAZE Procedure
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Medicare Advantage Chiropractor
This policy is required for:
- Medicare Advantage HMO-POS
- Medicare Advantage HMO-POS
- Medicare Advantage Skilled Nursing Facility Coverage Criteria
This policy is required for:
- Medicare Advantage HMO-POS
- Medicare Advantage HMO-POS
- Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Mitraclip Procedure
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Obesity Management, Surgical Approaches
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Oral Appliances for the Treatment of Obstructive Sleep Apnea
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Outpatient and Inpatient Chemotherapy Administration
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Pancreas Transplant Alone (PTA) and Autologous Islet Cell Transplants
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Medicare Advantage HMO-POS
- Marshfield Clinic Health System
- Peripheral Vascular Stents
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Physical, Occupational and Speech Therapy
This policy is required for:
- Private Duty Nursing in the Home Setting
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
Q-T
- Radiesse
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Radiofrequency Ablation to Treat Tumors
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Refractive Eye Surgery
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Repetitive Transcranial Magnetic Stimulation
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Revcovi
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Rezum Therapy
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Septoplasty/Rhinoplasty
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Skin Substitutes, Chemical Peels, Dermabrasions, and other Skin Procedures
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Sleep Studies
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Somatuline Depot (lanreotide)
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Spinal Cord Stimulation
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Spravato
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Swing Bed
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Synagis Injections
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Takhzyro® (lanadelumab-flyo)
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Telehealth
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- TMJ Benefit Review
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Tilt Table Testing
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Total Ankle Replacement
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Total Disc Arthroplasty
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Total Hip Replacement Surgical Precertification
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Transcatheter Aortic Valve Replacement (TAVR)
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Treatment of Autism Spectrum Disorders
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Treatment of Chronic Skin Conditions
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
U-Z
- Urinary Incontinence
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Vagus Nerve Stimulation for Epilepsy and Depression
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Varicose Vein Treatments
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Wearable Hearing Aids
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Zika Virus
This policy is required for:
- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS
- Zolgensma
This policy is required for:- BadgerCare Plus
- Commercial
- Family Health Center
- Marshfield Clinic Health System
- Medicare Advantage HMO-POS