| Ambetter Health Nebraska Clinical | Biofeedback | 2023-11-01 |
| Ambetter Health Nebraska Clinical | Burn Surgery | 2023-11-01 |
| Ambetter Health Nebraska Clinical | Proton and Neutron Beam Therapies | 2023-11-01 |
| Ambetter Health Nebraska Clinical | Selective Dorsal Rhizotomy in CP | 2023-11-01 |
| Wellcare Kentucky Medicaid Clinical | Biofeedback | 2023-11-01 |
| Wellcare Kentucky Medicaid Clinical | Selective Dorsal Rhizotomy in CP | 2023-11-01 |
| Wellcare Kentucky Medicaid Clinical | Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy | 2023-11-01 |
| Ambetter Health Texas Superior Marketplace Clinical | Polymerase chain reaction respiratory viral panel testing | 2023-11-01 |
| Sunshine Health Clinical Policy | Review for Personal Care Services Requests | 2023-11-01 |
| BCBS Iowa Medical Policies | Percutaneous Ultrasonic Tenotomy and Fasciotomy | 2023-11-01 |