Chronic Pulmonary Thromboendarterectomy
Surgery | April 1, 1998
CT Angiography, Head/Brain
Radiology | January 1, 2020
Proteogenomic Testing of Individuals With Cancer
Laboratory | January 1, 2020
Olaratumab (Lartruvo)
Prescription Drug | November 1, 2017
Genetic Testing for Inherited Cardiomyopathies and Channelopathies
Laboratory | April 1, 2013
Thoracic-Lumbo-Sacral Orthosis With Pneumatics
Durable Medical Equipment | February 1, 2002
Home Health Services Policy
Medicine | June 1, 2019
Natalizumab (Tysabri®)
Prescription Drug | January 1, 2014
Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
Therapy | April 1, 2013
Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias
Therapy | July 1, 2013
Biofeedback as a Treatment of Urinary Incontinence in Adults
Medicine | July 1, 1997
Identification of Microorganisms Using Nucleic Acid Probes
Laboratory | July 1, 1998
Chimeric Antigen Receptor Therapy for Hematologic Malignancies
Medicine | November 1, 2019
Uses of Monoclonal Antibodies
Prescription Drug | August 1, 2013
Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain
Medicine | August 1, 2013
Date Stamping of Claims
Administrative | March 1, 1991
Prolotherapy
Medicine | May 7, 1997
Photocoagulation of Macular Drusen
Other | July 1, 2008
Human Growth Hormone
Prescription Drug | September 1, 2014
Genetic Testing for FMR1 Mutations (including Fragile X Syndrome)
Laboratory | July 1, 2012
Transplant Rejection Testing
Laboratory | January 1, 2010
Bevacizumab in Advanced Adenocarcinoma of the Pancreas
Prescription Drug | August 1, 2013
Lumasiran for Primary Hyperoxaluria Type 1
Prescription Drug | June 1, 2021
Hematopoietic Stem Cell Transplantation for Autoimmune Diseases
Therapy | July 1, 2013
Tumor Treating Fields Therapy
Medicine | June 1, 2021
Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma
Therapy | July 1, 2013
Vitamin D Testing
Laboratory | January 1, 2016
Testing for Diagnosis of Active or Latent Tuberculosis
Laboratory | November 15, 2001
Bone Morphogenetic Protein
Surgery | July 1, 2004
Pre-implantation Genetic Testing
Laboratory | October 1, 2015
Three-Dimensional Printed Orthopedic Implants
Surgery | June 1, 2018
Botulinum Toxin
Prescription Drug | July 1, 1997
Videofluoroscopic Evaluation of Velopharyngeal Dysfunction
Radiology | July 17, 1996
Intravascular Brachytherapy for Preventing and Managing Restenosis After Percutaneous Transluminal Angioplasty (PTA)
Medicine | July 1, 1999
Daratumumab (Darzalex®) Injection
Prescription Drug | August 1, 2017
Testing for Alpha-1 Antitrypsin Deficiency
Laboratory | May 1, 2013
Local or Whole Body Hyperthermia
Medicine | July 1, 2002
CT Chest (Thorax)
Radiology | January 1, 2021
Golimumab (Simponi) for subcutaneous use
Prescription Drug | January 1, 2014
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Therapy | July 1, 2012
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions
Prescription Drug | February 1, 2013
Pegloticase (Krystexxa)
Prescription Drug | March 1, 2014
Laser Interstitial Thermal Therapy for Neurological Conditions
Therapy | December 1, 2021
Nerve Graft with Radical Prostatectomy
Surgery | November 1, 2001
Concurrent Care
Medicine | January 1, 1975
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty
Surgery | June 18, 2015
MUGA Scan
Radiology | January 1, 2020
MRI Breast
Radiology | December 1, 2000
MR Angiography Spinal Canal
Radiology | January 1, 2020
Prenatal Screening (nongenetics)
Laboratory | January 1, 2016
Vestibular Function Testing
Laboratory | December 1, 2017
Home Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease
Medicine | January 1, 2022
Discarded Drugs/Biologicals - Pharmaceutical Waste
Medicine | March 1, 2014
Treatment of Tinnitus
Therapy | August 23, 2001
Cosmetic/Reconstructive Services
Surgery | June 1, 1975
Autonomic Nervous System Testing
Medicine | February 1, 2015
Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities
Durable Medical Equipment | February 1, 2015
Vedolizumab (Entyvio™)
Prescription Drug | April 9, 2015
Genetic Testing and Genetic Expression Profiling in Patients With Cutaneous Melanoma
Laboratory | August 1, 2013
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
Surgery | December 1, 1995
Mepolizumab (Nucala®)
Prescription Drug | March 1, 2016
Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions
Other | April 4, 2013
Surgery for Groin Pain in Athletes
Surgery | June 1, 2015
Meniscal Allografts and Other Meniscal Implants
Surgery | December 1, 1995
Intra-Articular Hyaluronan Injections for Osteoarthritis
Medicine | February 1, 2013
Alcohol Injections for Treatment of Peripheral Neuromas
Medicine | October 1, 2018
Coordination of Benefits (COB) Excluding Medicare, Workers Compensation and Subrogation
Administrative | January 1, 1975
Intravitreal Corticosteroid Implants
Other | April 13, 2013
BRINEURA (cerliponase alfa)
Prescription Drug | January 1, 2018
Bezlotoxumab (Zinplava)
Prescription Drug | March 1, 2021
Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
Therapy | July 1, 2013
Intravenous Iron
Medicine | January 1, 2022
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Laboratory | May 1, 2011
Laparoscopic, Percutaneous and Transcervical Techniques for Uterine Fibroids Myolysis
Ob/Gyn/Reproduction | July 1, 2004
Immune Globulin Therapy
Therapy | January 16, 2013
Brain Natriuretic Peptide (BNP)
Laboratory | July 1, 2005
Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
Medicine | April 1, 2004
Vectra DA Blood Test for Rheumatoid Arthritis
Laboratory | May 1, 2014
Esophageal Pathology Testing
Laboratory | April 1, 2020
Auditory Brainstem Implant
Surgery | July 1, 2002
Intraoperative Neurophysiologic Monitoring
Surgery | January 24, 2013
UPPER EXTREMITY MRI (Hand, Wrist, Arm, Elbow, Long bone, or Shoulder MRI)
Radiology | December 1, 2019
Clinical Trials
Medicine | February 1, 2014
Orthopedic Applications of Platelet-Rich Plasma
Medicine | June 1, 2015
Neural Therapy
Medicine | January 1, 2012
Orthognathic Surgery
Surgery | July 1, 2013
Balloon Dilation of the Eustachian Tube
Medicine | October 1, 2020
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
Durable Medical Equipment | November 1, 1997
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Surgery | July 1, 2013
Computed Tomography to Detect Coronary Artery Calcification
Radiology | July 1, 2011
Desensitization Treatment for Peanut Allergies
Medicine | July 1, 2020
Genetic Testing for CHARGE Syndrome
Laboratory | April 1, 2014
Colorectal Cancer Screening
Medicine | October 1, 2018
Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors
Therapy | June 1, 2019
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
Medicine | October 1, 2013
CT (Virtual) Colonoscopy — Diagnostic
Radiology | January 1, 2021
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
Ob/Gyn/Reproduction | February 1, 2004
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Durable Medical Equipment | August 1, 2014
Endovascular Therapies for Extracranial Vertebral Artery Disease
Surgery | March 1, 2015
Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions
Surgery | August 1, 2013
Allergen Testing
Laboratory | September 1, 2013
Ultraviolet Light Therapy in the Home Setting (UVB)
Therapy | April 1, 2017
Deep Brain Stimulation
Surgery | January 1, 1998
Cimzia® (certolizumab pegol)
Prescription Drug | June 1, 2018
Hematopoietic Cell Transplantation for Solid Tumors of Childhood
Therapy | May 1, 2014
Transfusion Therapy for Hemolytic Disease of the Fetus and the Newborn
Ob/Gyn/Reproduction | March 1, 1996
Kidney Transplant
Surgery | December 1, 1995
Bevacizumab (Avastin) for Oncologic Use
Prescription Drug | January 1, 2014
CT Angiography, Upper Extremity
Radiology | January 1, 2021
Neutron Beam Therapy (NBT)
Radiology | January 1, 2021
Inhaled Nitric Oxide
Therapy | August 1, 2000
ZOMETA (zoledronic acid)
Prescription Drug | July 1, 2018
Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder
Mental Health | November 1, 2013
Viltepso® (Viltolarsen)
Prescription Drug | June 1, 2021
Minimally Invasive Hip and Knee Arthroplasty
Surgery | April 1, 2004
Cognitive Rehabilitation
Therapy | November 1, 1997
Pelvis Magnetic Resonance Angiography
Radiology | January 1, 2021
Gamma-glutamyl Transferase
Laboratory | August 15, 2020
Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Medicine | April 1, 2013
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Other | November 1, 1997
MRI Cervical Spine
Radiology | January 1, 2020
Treatment of Chest Wall Deformities (Congenital or Acquired)
Surgery | January 1, 2014
Omalizumab (Xolair®)
Prescription Drug | April 1, 2014
Dynamic Posturography
Medicine | December 1, 1995
Urinary Tumor Markers for Bladder Cancer
Laboratory | January 23, 1998
Deleted Claims
Administrative | June 1, 1992
Home Spirometry
Medicine | March 1, 1999
Positional Magnetic Resonance Imaging (MRI)
Radiology | June 1, 2008
Transcatheter Pulmonary Valve Implantation
Surgery | January 16, 2013
CT Lower Extremity (Ankle, Foot, Hip or Knee)
Radiology | January 1, 2020
Pertuzumab for Treatment of Malignancies
Prescription Drug | August 1, 2013
CT Thoracic Spine
Radiology | January 1, 2020
Catheter Ablation as Treatment for Atrial Fibrillation
Medicine | July 1, 2004
BioZorb®
Surgery | July 1, 2019
Artificial Pancreas Device Systems
Medicine | February 1, 2015
Temporomandibular Joint Dysfunction
Medicine | July 1, 2010
Threshold Electrical Stimulation as a Treatment of Motor Disorders
Durable Medical Equipment | April 1, 2000
Vertical Expandable Prosthetic Titanium Rib
Surgery | September 1, 2007
Axial Lumbosacral Interbody Fusion
Surgery | December 1, 2011
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
Surgery | July 1, 2013
CT Angiography, Neck
Radiology | January 1, 2020
Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes
Medicine | August 1, 2013
Phototherapeutic Keratectomy
Surgery | November 4, 1998
Measurement of Thromboxane Metabolites for Aspirin Resistance
Laboratory | January 1, 2013
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
Durable Medical Equipment | August 1, 2000
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer
Therapy | July 1, 1996
Neurofeedback
Medicine | January 1, 1998
Diagnostic Testing of Iron Homeostasis & Metabolism
Laboratory | January 1, 2016
Leadless Cardiac Pacemakers
Medicine | December 1, 2019
Radioactive Seed Localization of Nonpalpable Breast Lesions
Radiology | October 1, 2013
Blepharoplasty (Upper and Lower)
Surgery | January 1, 1982
Pain Management Services (Chronic Pain and Rehabilitation Therapies)
Medicine | June 1, 1987
Metabolite Markers of Thiopurines Testing
Laboratory | December 6, 2000
Pharmacogenetic Testing
Laboratory | April 1, 2019
Ocrelizumab (Ocrevus™)
Prescription Drug | May 1, 2017
In Vitro Chemoresistance and Chemosensitivity Assays
Laboratory | March 1, 1996
Use of Common Genetic Variants (Single Nucleotide Polymorphisms) To Predict Risk of Non-Familial Breast Cancer
Laboratory | July 1, 2012
Use of Magnetic Resonance Imaging to Monitor Integrity of Silicone Gel-Filled Breast Implants
Radiology | June 1, 2010
Hemoglobin A1C
Laboratory | January 1, 2016
CT Angiography, Abdomen
Radiology | January 1, 2020
Facet Arthroplasty
Surgery | June 1, 2013
Hip Resurfacing
Surgery | February 1, 2009
Microwave Tumor Ablation
Surgery | December 6, 2012
Dynamic Spinal Visualization and Vertebral Motion Analysis
Radiology | February 1, 2007
Patient-Controlled End of Range Motion Stretching Devices
Durable Medical Equipment | February 1, 2015
Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy and Miscellaneous Musculoskeletal Conditions
Durable Medical Equipment | April 2, 2003
Celiac Disease Testing
Laboratory | April 1, 2003
Treatment of Varicose Veins/Venous Insufficiency
Surgery | February 21, 2013
Low Intensity Pulsed Ultrasound Fracture Healing Device
Durable Medical Equipment | December 23, 1995
Floor Limits
Administrative | August 15, 1988
Genetic Testing for Adolescent Idiopathic Scoliosis
Laboratory | June 1, 2013
Speech Generating Devices
Durable Medical Equipment | October 1, 2019
Gender Reassignment Surgery
Surgery | March 1, 2016
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma
Therapy | December 11, 2012
Enhanced External Counterpulsation (EECP)
Medicine | January 1, 2003
CT Upper Extremity
Radiology | January 1, 2020
Therapeutic Drug Monitoring for 5-Fluorouracil
Laboratory | October 1, 2019
Salivary Hormone Testing
Laboratory | December 1, 2005
Decompression of the Intervertebral Disc Using Laser (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty™)
Surgery | October 1, 2003
Genicular Nerve Blocks and Ablation for Chronic Knee Pain
Medicine | August 1, 2019
Radiation Therapy for Non-Cancerous Conditions
Radiology | January 1, 2021
General Genetic Testing, Germline Disorders
Laboratory | April 1, 2017
Composite Tissue Allotransplantation of the Hand and Face
Surgery | August 1, 2013
Functional Neuromuscular Electrical Stimulation , Robotic-assisted Rehabilitation & Robotic-assisted Orthotics
Therapy | March 15, 1996
Occupational Therapy
Therapy | June 1, 2013
Chromoendoscopy as an Adjunct to Colonoscopy
Medicine | April 1, 2012
Infliximab
Prescription Drug | June 25, 2013
Diagnosis of Obstructive Sleep Apnea Syndrome
Medicine | May 1, 2013
Transcatheter Arterial Chemoembolization To Treat Primary or Metastatic Liver Malignancies
Therapy | July 1, 2013
CT Angiography, Abdomen and Pelvis
Radiology | January 1, 2020
Magnetoencephalography/Magnetic Source Imaging
Radiology | December 1, 1999
CT Angiography, Pelvis
Radiology | January 1, 2020
Preventive Services for Non-Grandfathered (PPACA) Plans: Behavioral Counseling for Prevention
Medicine | April 1, 2014
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Therapy | June 1, 2015
Endobronchial Brachytherapy
Therapy | March 1, 1999
Evaluation of Hearing Impairment
Other | November 1, 1997
Transcatheter Aortic-Valve Implantation for Aortic Stenosis
Surgery | December 1, 2012
Hospital Medical Services (Inpatient and Observation) and Consultation
Medicine | January 1, 1975
Reverse Shoulder Arthroplasty
Surgery | October 1, 2009
CT Head/Brain
Radiology | January 1, 2020
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy
Radiology | January 1, 1999
Genetic Testing for Alpha- and Beta-Thalassemia
Laboratory | April 1, 2014
Ambulatory or Video Electroencephalogram (EEG) Monitoring, Including Digital Analysis of Electroencephalogram
Medicine | May 1, 2020
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas
Therapy | July 1, 2013
Scintimammography and Gamma Imaging of the Breast and Axilla
Radiology | January 1, 1998
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty and Biacuplasty
Surgery | December 7, 1999
Total Artificial Hearts and Implantable Ventricular Assist Devices
Surgery | November 1, 1996
Acupuncture and Dry Needling
Surgery | November 12, 1998
Intraoperative Radiotherapy
Therapy | December 1, 2011
Lower Extremity CTA/CTV
Radiology | January 1, 2020
Bioimpedance Devices for Detection and Management of Lymphedema
Medicine | April 1, 2011
Vacuum Therapy as a Treatment for Female Sexual Dysfunction
Medicine | November 18, 2001
Human Papillomavirus (HPV) Vaccines
Medicine | October 1, 2011
InflammaDry Test
Laboratory | December 1, 2016
Fibromyalgia Testing
Laboratory | July 1, 2021
Wearable Cardioverter-Defibrillators
Medicine | April 1, 2003
Prenatal Screening for Fetal Aneuploidy
Laboratory | April 15, 2003
Crizanlizumab-tmca (Adakveo)
Prescription Drug | February 1, 2020
Targeted Phototherapy and Psoralen With Ultraviolet A for Vitiligo
Medicine | May 1, 2013
Lyme Disease Testing
Laboratory | February 1, 2017
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
Laboratory | November 28, 2012
Molecular Analysis for Gliomas
Laboratory | February 1, 2015
Patient-Controlled Analgesia
Medicine | May 6, 1997
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Surgery | October 1, 2003
Extended-Release Injectable (Sublocade)
Prescription Drug | July 1, 2018
CT Angiography, Chest (Noncoronary)
Radiology | January 1, 2020
Timely Filing
Administrative | June 1, 1992
MR Angiography Upper Extremity
Radiology | January 1, 2021
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
Medicine | March 1, 1996
Genetic Testing for Li-Fraumeni Syndrome
Laboratory | July 1, 2014
Ustekinumab (Stelara)
Prescription Drug | June 1, 2018
Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma
Other | March 1, 2011
Esophageal pH Monitoring
Medicine | July 1, 1996
Cardiac Biomarkers for Myocardial Infarction
Laboratory | August 13, 2018
Donor Lymphocyte Infusion for Malignancies Treated With an Allogeneic Hematopoietic Cell Transplant
Medicine | January 1, 1998
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery
Surgery | July 1, 2019
MRI Bone Marrow
Radiology | January 1, 2020
T-Wave Alternans
Medicine | December 23, 2000
Breast Surgical Procedures/Prosthesis
Surgery | October 1, 1977
Microprocessor-Controlled Prosthetic for the Lower Limb
Durable Medical Equipment | October 1, 2003
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
Laboratory | November 15, 2001
Open and Thoracoscopic Approaches To Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
Surgery | December 1, 1995
Mitomycin for Pyelocalyceal Solution (Jelmyto)
Prescription Drug | September 1, 2020
Monoclonal Antibody Therapies for Migraine Prevention
Prescription Drug | March 1, 2019
Hippotherapy
Therapy | July 1, 1999
Bone Turnover Markers Testing
Laboratory | July 1, 1999
Immune Cell Function Assay
Laboratory | July 1, 2013
COVID-19 Testing
Laboratory | May 1, 2020
Knee Braces, Orthopaedic Casts, Splints
Durable Medical Equipment | November 1, 1997
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure
Durable Medical Equipment | December 1, 1995
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
Therapy | August 1, 2012
Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure
Radiology | August 1, 2013
Diagnosis and Treatment of Non-Surgical Sacroiliac Joint Pain
Radiology | February 1, 2013
Ultrafiltration in Decompensated Heart Failure
Medicine | February 1, 2007
Mental Health Services
Mental Health | June 1, 2020
Genetic Testing for Rett Syndrome
Laboratory | April 1, 2013
Genetic Testing for Hereditary Hearing Loss
Laboratory | December 1, 2014
Esketamine Nasal Spray for Treatment-Resistant Depression
Laboratory | April 1, 2020
Biochemical Markers of Alzheimer Disease and Dementia
Laboratory | July 1, 1999
Blinatumomab (Blincyto)
Prescription Drug | December 1, 2015
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee
Surgery | April 23, 2003
Hypnosis
Medicine | December 1, 1995
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies
Prescription Drug | August 1, 2013
Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
Medicine | March 1, 2014
Spinal Cord and Dorsal Root Ganglion Stimulation
Surgery | March 6, 1996
HIV Genotyping and Phenotyping
Laboratory | April 1, 2000
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Laboratory | June 1, 2009
CT Abdomen
Radiology | January 1, 2020
Brain (Head) MRA/MRV
Radiology | January 1, 2021
Radium Ra 223 (Xofigo®) Injection
Medicine | August 1, 2017
Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease
Radiology | July 1, 2012
Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer
Radiology | December 1, 2002
Maternity/Obstetrical Care Benefits
Other | July 1, 1998
Digital Health Therapies for Substance Use Disorders
Therapy | August 1, 2020
Hematopoietic Colony-Stimulating Factors (CSFs)
Prescription Drug | June 1, 2018
Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
Surgery | August 1, 2016
Biofeedback as a Treatment of Fecal Incontinence or Constipation
Medicine | December 1, 2003
Chiropractic Services
Other | August 1, 1988
Eteplirsen for Duchenne Muscular Dystrophy
Medicine | November 1, 2018
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Therapy | May 1, 2013
CT Pelvis
Radiology | January 1, 2020
Home Prothrombin Time Monitoring
Durable Medical Equipment | September 1, 2010
Radiopharmaceutical Tumor Localization (SPECT), Single Area
Radiology | November 1, 2020
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Surgery | October 3, 2002
Erythopoiesis Stimulating Agents and Darbepoetin Alfa (Aranesp)
Prescription Drug | December 1, 1995
Cryoablation, Radiofrequency Ablation and Laser Ablation for Treatment of Chronic Rhinitis
Surgery | January 1, 2022
Drug Claim Processing
Administrative | May 1, 1992
Lynch Syndrome Testing
Laboratory | May 1, 2017
Controls
Administrative | August 1, 1988
Percutaneous Vertebroplasty and Sacroplasty
Radiology | April 10, 2013
Ocular Photoscreening in the Primary Care Physician's Office as a Screening Tool to Detect Amblyogenic Factors
Other | September 1, 2007
Pembrolizumab (Keytruda)
Prescription Drug | November 1, 2014
Catheter Ablation for Cardiac Arrhythmias
Medicine | December 1, 1995
Hematopoietic Cell Transplantation for Hodgkin Lymphoma
Therapy | July 1, 2013
Breast Duct Endoscopy
Medicine | April 1, 2003
Genetic Testing for Epilepsy
Laboratory | January 1, 2014
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease
Laboratory | February 1, 2000
Testing of Homocysteine Metabolism-Related Conditions
Laboratory | March 1, 2017
Quantitative Sensory Testing
Medicine | June 1, 2013
Brain (Head) MRS
Radiology | April 1, 2000
Oral Screening, Lesion Identification Systems and Genetic Screening
Laboratory | March 1, 2014
Surgical Treatment of Bilateral Gynecomastia
Surgery | August 1, 2013
Low-Field MRI
Radiology | January 1, 2020
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
Surgery | December 1, 2002
Oncologic uses of Interferon Therapy
Therapy | December 1, 1995
Hyperbaric Oxygen Therapy
Medicine | December 1, 1995
Liquid Biopsy
Laboratory | July 1, 2016
Repository Corticotropin Injection
Prescription Drug | October 1, 2013
TEMPORAL BONE, MASTOID, ORBITS CT
Radiology | January 1, 2020
Vitamin B12 and Methylmalonic Acid Testing
Laboratory | January 1, 2016
NECK MRA/MRV
Radiology | January 1, 2021
Telemedicine
Medicine | March 6, 2013
ABDOMEN MRA (Angiography)
Radiology | January 1, 2021
Abatacept (Orencia®)
Prescription Drug | April 1, 2014
Mutation Analysis in Myeloproliferative Neoplasms
Laboratory | February 1, 2011
Cellular Immunotherapy for Prostate Cancer
Therapy | June 1, 2010
Genetic Testing of CADASIL Syndrome
Laboratory | August 1, 2013
Periureteral Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR)
Surgery | March 2, 2005
Corporate Administrative/Medical Policy Guidelines (Medical Necessity, Investigational/Experimental)
Other | January 1, 1975
Belinostat (Beleodaq)
Prescription Drug | December 1, 2015
Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
Radiology | December 1, 2014
Allogeneic Pancreas Transplant
Surgery | December 15, 1996
TECENTRIQ™ (atezolizumab)
Prescription Drug | June 1, 2016
Orthodontic Treatment
Medicine | January 1, 2014
Trastuzumab
Prescription Drug | April 4, 2013
Aqueous Shunts and Devices for Glaucoma
Other | October 1, 2009
Genetic Testing for Cystic Fibrosis
Laboratory | July 1, 2017
BCR-ABL1 Testing
Laboratory | August 1, 2013
Outpatient Pulmonary Rehabilitation
Therapy | July 6, 2005
Vertebral Axial Decompression
Therapy | May 17, 1997
Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management (Ductal Lavage and Suction Collection Systems)
Laboratory | August 1, 2001
Immune Prophylaxis for Respiratory Syncytial Virus
Prescription Drug | March 1, 2010
Air Fluidized Beds
Durable Medical Equipment | December 1, 1995
Brain PET Scan
Radiology | January 1, 2021
Progesterone Therapy as a Technique To Reduce Preterm Delivery in High-Risk Pregnancies
Ob/Gyn/Reproduction | December 3, 2003
Islet Cell Transplantation
Surgery | August 1, 2001
Buprenorphine Implant for Treatment of Opioid Dependence
Prescription Drug | July 1, 2019
Laboratory/Pathology Services
Laboratory | April 1, 1997
Onychomycosis Testing
Laboratory | April 1, 2020
Lipid Apheresis
Therapy | July 1, 1999
Laser Treatment of Onychomycosis
Medicine | June 1, 2013
Aerosolized Antibiotics as a Treatment of Chronic Sinusitis
Medicine | July 15, 2004
Biofeedback for Miscellaneous Indications
Medicine | July 1, 1997
Registered Nurses Practicing in Extended Roles
Other | May 1, 1993
Steroid-Eluting Sinus Stents and Implants
Surgery | August 1, 2013
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection
Laboratory | November 1, 1996
Physical Therapy
Therapy | June 1, 2013
Cooling Devices Used in the Outpatient Setting
Durable Medical Equipment | November 1, 2004
Interspinous and Interlaminar Stabilization/Distraction Devices Spacers
Durable Medical Equipment | January 1, 2007
Extracorporeal Shock Wave Treatment for Plantar Faciitis and Other Musculoskeletal Conditions
Durable Medical Equipment | May 1, 2001
Corneal Collagen Cross-linking
Other | April 1, 2012
MRI MRCP Abdomen
Radiology | January 1, 2020
Electrical and Electromagnetic Stimulation for the Treatment of Arthritis
Durable Medical Equipment | April 1, 2009
Nerve Fiber Density Testing
Laboratory | June 1, 2010
Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension
Prescription Drug | January 1, 1998
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction Due to Benign Prostatic Hyperplasia (BPH)
Surgery | February 1, 2016
Intradialytic Parenteral Nutrition
Therapy | December 1, 2003
Manipulation Under Anesthesia
Therapy | May 1, 2002
Zolgensma® (Onasemnogene Abeparvovec-Xioi)
Prescription Drug | June 1, 2019
Lower Extremity MRA/MRV
Radiology | January 1, 2021
Whole Genome and Whole Exome Sequencing
Laboratory | October 1, 2013
Hyperthermia With Radiation
Radiology | January 1, 2021
Surgical and Ablative Treatments for Chronic Headaches
Surgery | August 1, 2013
Intracellular Micronutrient Analysis
Laboratory | May 1, 2013
Inpatient Intestinal Rehabilitation Therapy
Medicine | November 1, 2001
Radicava (edaravone injection)
Prescription Drug | November 1, 2017
Thermal Capsulorrhaphy as a Treatment of Joint Instability
Surgery | July 2, 2002
Retinal Prosthesis
Other | February 1, 2005
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Durable Medical Equipment | April 1, 1998
Cluneal Nerve Block For Treatment Of Low Back Pain
Medicine | August 1, 2021
Retinal Telescreening for Diabetic Retinopathy
Other | November 1, 2004
Diagnostic Testing of Influenza
Laboratory | January 1, 2016
Testosterone Testing
Laboratory | January 1, 2016
Sacral Nerve Neuromodulation/Stimulation
Surgery | November 5, 1998
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Durable Medical Equipment | July 1, 1997
Allergy Immunotherapy
Medicine | October 15, 2000
β-Hemolytic Streptococcus Testing
Laboratory | February 1, 2019
MRI Lumbar Spine
Radiology | January 1, 2020
Non-Pharmacologic Treatment of Rosacea
Medicine | February 1, 2011
Lung and Lobar Lung Transplant
Surgery | July 1, 1996
Injectable Clostridial Collagenase for Fibroproliferative Disorders
Prescription Drug | January 29, 2013
Gene Therapy for Inherited Retinal Dystrophy/Luxturna™
Prescription Drug | May 1, 2019
Diagnosis of Vaginitis Including Multi-Target PCR Testing
Laboratory | February 1, 2000
Bronchial Thermoplasty
Surgery | February 1, 2011
Tagraxofusp-erzs (Elzonris)
Prescription Drug | July 1, 2019
Qualified Medical Child Support
Administrative | October 9, 1996
Bone Mineral Density Studies
Radiology | March 1, 2013
Spinal Epidural Injections
Therapy | February 1, 2016
MRI Temporomandiublar Joint (TMJ)
Radiology | January 1, 2020
MRI Chest (Thorax)
Radiology | January 1, 2021
Enteral Carbidopa and Levodopa Intestinal Gel Suspension
Medicine | March 1, 2015
Endovascular Stent Grafts for Disorders of the Thoracic Aorta
Surgery | July 1, 2013
Biofeedback as a Treatment of Headache
Medicine | April 1, 1998
Chimeric Antigen Receptor Therapy for Multiple Myeloma
Prescription Drug | June 1, 2021
Ambulance and Medical Transport Services
Other | April 15, 1998
Abdominoplasty, Panniculectomy and Lipectomy
Surgery | June 1, 2015
Intravenous Antibiotic Therapy for Lyme Disease
Prescription Drug | January 1, 1998
Laser-Assisted Tonsillectomy
Surgery | July 1, 1997
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
Laboratory | August 1, 2013
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus
Medicine | February 1, 2011
BRCA
Laboratory | July 1, 1997
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Medicine | June 1, 2005
Plugs for Fistula Repair
Surgery | August 1, 2013
General Inflammation Testing
Laboratory | November 1, 2018
Molecular Testing for Chronic Heart Failure and Heart Transplant
Laboratory | February 1, 2015
Prescription Medication and Illicit Drug Testing in the Outpatient Setting
Laboratory | November 1, 2016
Laser Treatment of Active Acne
Medicine | November 1, 2004
Teprotumumab-trbw (TEPEZZA™)
Prescription Drug | February 1, 2021
Pricing Services (Professional Services and Blue Card ITS Home/Control Plan and Blue Card ITS Host Plan)
Administrative | August 1, 1988
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
Therapy | June 1, 2013
Noncontact Radiant Heat Bandage for the Treatment of Wounds
Medicine | May 1, 2001
Brexanolone for Postpartum Depression
Prescription Drug | August 1, 2019
Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas
Therapy | July 1, 2013
Breast Pumps
Durable Medical Equipment | July 1, 2013
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders
Prescription Drug | April 1, 2004
Ingestible pH and Pressure Capsule
Medicine | February 1, 2011
MRI Brain (Includes Internal Auditory Canal)
Radiology | January 1, 2020
Chelation Therapy for Off-Label Uses
Therapy | December 1, 1995
Diagnostic Testing of Most Common Sexually Transmitted Infections
Laboratory | February 1, 2019
Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease
Durable Medical Equipment | April 1, 2003
Ramucirumab (Cyramza®)
Prescription Drug | December 1, 2015
Dermatologic Applications of Photodynamic Therapy
Medicine | November 1, 2001
Nusinersen for Spinal Muscular Atrophy
Prescription Drug | March 1, 2017
Genetic Testing for Neurodegenerative Disorders
Laboratory | January 1, 2020
Durable Medical Equipment (DME)
Durable Medical Equipment | August 1, 1988
Daily Hemodialysis and Hemodialysis in the Home Setting
Therapy | November 1, 2013
Unicompartmental and Bicompartmental Knee Arthroplasties
Surgery | June 1, 2013
Enteral Feeding In-Line Cartridge (EFIC™)/Immobilized Lipase Cartridge/Relizorb™
Prescription Drug | March 1, 2018
Folate Testing
Laboratory | October 1, 2018
Accident and Medical Emergency Services
Administrative | January 15, 1997
Prenatal Genetic and Chromosomal Metabolic Testing
Ob/Gyn/Reproduction | December 6, 1995
Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee
Surgery | December 6, 2012
VYONDYS 53 (golodirsen)
Prescription Drug | December 1, 2019
SIMPONI ARIA (golimumab injection for intravenous use)
Prescription Drug | May 1, 2016
Fecal Microbiota Transplantation
Medicine | July 1, 2014
Computer-Assisted Navigation for Orthopedic Procedure
Surgery | February 1, 2004
Implantable Hormone Pellets for Females
Prescription Drug | August 1, 2010
Myocardial Perfusion Imaging (Nuc Card)
Radiology | January 1, 2020
Peripheral Subcutaneous Field Stimulation
Surgery | August 1, 2013
FDG Using Camera-Based Imaging (FDG-SPECT)
Radiology | August 1, 2000
Fractional Flow Reserve CT
Radiology | October 1, 2017
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Surgery | June 1, 2010
CT Lumbar Spine
Radiology | January 1, 2020
Genetic Testing for Lactase Insufficiency
Laboratory | June 1, 2013
Genetic Testing for Familial Cutaneous Malignant Melanoma
Laboratory | December 18, 2012
Genetic Testing for Fanconi Anemia
Laboratory | December 1, 2014
Low-Level Laser Therapy
Medicine | April 1, 2003
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
Other | August 1, 2013
Multispectral Digital Skin Lesion Analysis
Medicine | January 1, 2016
Rituximab
Prescription Drug | April 1, 2014
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation
Therapy | August 1, 2013
Telehealth
Medicine | October 1, 2017
Lysis of Epidural Adhesions
Therapy | November 1, 1998
Thermography
Radiology | March 1, 1996
Cemiplimab-rwlc (Libtayo®)
Prescription Drug | September 1, 2019
Minimal Residual Disease
Laboratory | January 1, 2021
Pneumatic Compression Pumps for Treatment of Lymphedema
Durable Medical Equipment | July 1, 1998
Uterus Transplantation for Absolute Uterine Factor Infertility
Medicine | May 1, 2022
Ablation of Peripheral Nerves to Treat Pain
Surgery | May 1, 2016
Ipilimumab (Yervoy)
Prescription Drug | September 1, 2014
Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)
Therapy | April 1, 2013
Confidential Records and Information (Security, Storage and Destruction)
Administrative | October 1, 1976
CT Soft Tissue Neck
Radiology | January 1, 2021
Bronchial Valves
Surgery | August 1, 2013
Electromagnetic Navigation Bronchoscopy
Surgery | December 1, 2009
Radiopharmaceutical Agents and Other In Vivo Diagnostic Aids
Radiology | January 1, 2006
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
Therapy | July 1, 2013
Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome
Ob/Gyn/Reproduction | April 1, 2004
Oncologic Applications of PET Scanning
Radiology | February 1, 2013
Negative Pressure Wound Therapy in the Outpatient Setting
Durable Medical Equipment | June 1, 2013
Medical Records Documentation Standards
Other | June 1, 2018
Molecular Testing of Pulmonary Specimens
Laboratory | August 1, 2017
Chromosomal Microarray
Laboratory | July 1, 2014
Chemical Peels
Therapy | April 1, 1998
Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
Surgery | August 1, 2013
Imfinzi (durvalumab)
Prescription Drug | March 1, 2019
Placental and Umbilical Cord Blood as a Source of Stem Cells
Surgery | November 5, 1996
Genetic Testing for Hereditary Pancreatitis
Laboratory | April 1, 2014
Adoptive Immunotherapy
Medicine | December 1, 1996
Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
Medicine | April 1, 2013
Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds
Surgery | July 1, 2003
Continuous Passive Motion (CPM) in the Home Setting
Durable Medical Equipment | January 15, 2013
Insulin Potentiation Therapy
Medicine | February 1, 2005
Functional MRI Brain
Radiology | February 1, 2007
Surgical Treatment of Femoroacetabular Impingement
Surgery | June 1, 2010
Positron Emission Mammography (PEM)
Radiology | February 1, 2011
Service Intensity Guidelines
Mental Health | January 1, 2019
Sphenopalatine Ganglion Block for Headache
Medicine | August 1, 2017
Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition
Radiology | February 1, 2012
Vagus Nerve Blocking Therapy for Treatment of Obesity
Surgery | September 1, 2016
Sensory Integration Therapy and Auditory Integration Therapy
Therapy | April 1, 2000
Magnetic Resonance — Guided Focused Ultrasound
Surgery | June 1, 2011
Intensity-Modulated Radiation Therapy (IMRT): Abdomen and Pelvis
Therapy | August 1, 2012
Emapalumab-lzsg (Gamifant)
Prescription Drug | July 1, 2019
Testing for Diagnosis of Helicobacter Pylori
Laboratory | January 23, 1998
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
Durable Medical Equipment | May 1, 2011
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Surgery | December 1, 2000
Preventive Services for Non-Grandfathered (PPACA) Plans: USPSTF recommended services
Medicine | January 1, 2015
Aducanumab for Alzheimer Disease
Prescription Drug | July 1, 2021
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
Therapy | July 1, 2013
Bulking Agents for the Treatment of Vocal Cord Paralysis
Prescription Drug | December 1, 2015
Genetic Testing for Familial Hypercholesterolemia
Laboratory | July 1, 2016
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Surgery | August 1, 2001
Testosterone Replacement Therapies
Prescription Drug | April 1, 2014
Viscocanalostomy and Canaloplasty
Surgery | October 24, 2012
Urine Culture Testing for Bacteria
Laboratory | December 1, 2018
Gene Expression Testing for Breast Cancer Prognosis
Laboratory | July 1, 2004
Medical Policy Development and Review
Other | January 1, 2017
PARSABIV™ (etelcalcetide)
Prescription Drug | March 1, 2018
Transition of Care (TOC)/Continuation of Care (COC)
Administrative | September 15, 2020
Percutaneous Tibial Nerve Stimulation
Surgery | February 1, 2007
Octreotide Acetate (Sandostatin)
Prescription Drug | January 1, 2014
Total Ankle Replacement
Surgery | May 1, 2001
Surgical Guidelines (Secondary, Multiple Procedures, Co-Surgeons, Assistant Surgeons, Standby Physicians, Microsurgery/Microdissection)
Surgery | April 1, 1987
Total Parenteral Nutrition and Enteral Nutrition in the Home
Durable Medical Equipment | June 1, 2013
Digital Breast Tomosynthesis
Radiology | July 1, 2011
Hereditary Angioedema Drug Therapy
Prescription Drug | December 1, 2014
Inpatient Rehabilitation
Therapy | August 1, 1995
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
Laboratory | August 1, 2013
Interspinous Fixation (Fusion) Devices
Surgery | June 1, 2013
Lung Volume Reduction Surgery for Severe Emphysema
Surgery | July 1, 1999
Surgical Ventricular Restoration
Surgery | June 1, 2008
Transcutaneous Electrical Nerve Stimulation (TENS)
Durable Medical Equipment | November 1, 1996
Women's Preventive Services
Medicine | June 1, 2015
Paravertebral Facet Joint Injections/Blocks
Medicine | February 1, 2016
Testing for Mosquito- or Tick-Related Infections
Laboratory | February 1, 2019
Antineoplaston Therapy and Sodium Phenylbutyrate
Prescription Drug | October 1, 2011
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Therapy | July 1, 1996
Allograft Injection for Degenerative Disc Disease
Medicine | May 1, 2021
Cardiac Applications of PET Scanning
Radiology | January 1, 2021
Anesthesia Services
Other | January 1, 1975
Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
Surgery | November 1, 2011
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
Laboratory | March 1, 2005
Drug Coverage
Prescription Drug | January 1, 1980
Thyroid Disease Testing
Laboratory | January 1, 2016
Endothelial Keratoplasty
Other | January 15, 2013
Assignment Guidelines and Assignment Conflicts
Administrative | May 1, 1992
Genetic Testing and Genetic Expression Profiling in Patients With Uveal Melanoma
Laboratory | July 1, 2014
Cardiovascular Disease Risk Assessment
Laboratory | January 1, 2018
Orthoptic Training for the Treatment of Vision or Learning Disabilities
Other | July 1, 1996
Oncologic Applications of Interleukin-2 (Aldesleukin) When Used as Monotherapy
Therapy | December 1, 1995
CT Angiography, Abdominal Arteries
Radiology | January 1, 2020
Whole Gland Cryoablation of Prostate Cancer
Surgery | May 1, 2013
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Surgery | July 1, 2013
Minimally Invasive Coronary Artery Bypass Graft Surgery
Other | June 1, 2011
Surgical Treatments for Lymphedema and Lipedema
Surgery | December 1, 2020
Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography
Radiology | February 1, 2013
Dry Needling of Trigger Point Injections for Myofascial Pain
Surgery | August 1, 2016
Interventions for Progressive Scoliosis
Medicine | June 1, 2010
Venous and Arterial Thrombosis Risk Testing
Laboratory | April 1, 2013
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
Surgery | October 1, 2019
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer
Laboratory | June 15, 2020
Administrative Charges for Medical Services
Administrative | January 1, 1975
Genetic Testing for Connective Tissue Disorders
Laboratory | May 1, 2017
Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
Therapy | February 1, 2011
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
Radiology | February 17, 2002
Genetic Testing for Acute Myeloid Leukemia
Laboratory | December 1, 2014
Whole Body Computed Tomography Scan as a Screening Test
Radiology | December 17, 2003
Nivolumab (Opdivo)
Prescription Drug | June 1, 2015
Extracorporeal Membrane Oxygenation for Adult Conditions
Therapy | February 1, 2015
Molecular Markers in Fine Needle Aspirates of the Thyroid
Laboratory | February 1, 2012
Transcatheter Mitral Valve Repair
Medicine | December 1, 2014
Quantose Impaired Glucose Tolerance (IGT) Test
Laboratory | July 1, 2016
Serum Testing for Evidence of Mild Traumatic Brain Injury
Laboratory | May 1, 2018
Radiation Oncology Services
Medicine | July 1, 2000
Genetic Testing for Mental Health Conditions
Laboratory | January 1, 2014
Percutaneous Treatment of Fracture Non-Unions or Bone Defects With Autologous Bone Marrow With or Without Demineralized Bone Matrix (DBM)
Medicine | May 1, 2013
Neuromuscular Electrical Stimulation (NMES)
Durable Medical Equipment | March 1, 2007
Gas Permeable Scleral Contact Lens
Other | February 1, 2013
Cerebral Perfusion Analysis CT
Radiology | November 1, 2007
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Medicine | December 1, 2000
Eye Movement Desensitization and Reprocessing (EMDR) Therapy
Mental Health | January 1, 2018
Myocardial Strain Imaging
Medicine | April 1, 2020
Vasectomy Using a Polymeric Clip
Surgery | April 18, 2004
Sufentanil Sublingual Tablet (Dsuvia)
Prescription Drug | July 1, 2019
Occlusion of Uterine Arteries Using Transcatheter Embolization
Ob/Gyn/Reproduction | July 1, 1999
Extracorporeal Photopheresis
Therapy | August 2, 2000
Vertebral Fracture Assessment with Densitometry
Radiology | February 4, 2011
Baroreflex Stimulation Devices
Therapy | August 1, 2013
Light Therapy for Dermatologic Conditions
Therapy | April 1, 2017
Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
Surgery | September 1, 2007
Avelumab (Bavencio®)
Prescription Drug | November 1, 2017
Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
Radiology | June 1, 2013
Home Phototherapy for Neonatal Jaundice
Durable Medical Equipment | March 1, 1996
Small Bowel/Liver and Multivisceral Transplant
Surgery | December 1, 1995
Hematopoietic Cell Transplantation for Primary Amyloidosis
Therapy | April 10, 2013
Transanal Radiofrequency Treatment of Fecal Incontinence
Medicine | July 1, 2003
Suit Therapy
Therapy | July 1, 2013
Sinus Maxillofacial CT
Radiology | January 1, 2020
MRI Pelvis
Radiology | January 1, 2020
Liver Transplant and Combined Liver-Kidney Transplant
Surgery | December 1, 1995
Intracardiac Ischemia Monitoring
Medicine | December 1, 2018
Optical Coherence Tomography of the Anterior Eye Segment
Other | September 1, 2008
Erectile Dysfunction
Laboratory | May 1, 1997
Stem-cell Therapy for Peripheral Arterial Disease
Therapy | May 1, 2013
Influenza Vaccine
Medicine | October 31, 2008
Cardiac Rehabilitation in the Outpatient Setting
Therapy | August 1, 2013
MR Angiography Chest
Radiology | November 1, 1997
Heart/Lung Transplant
Surgery | July 1, 1996
Chronic Intermittent Intravenous Insulin Therapy (CIIIT)
Therapy | November 1, 2001
Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation
Radiology | May 1, 2013
Advanced Approval Waiver
Administrative | May 1, 1995
Electrophrenic Pacemaker
Surgery | March 1, 1996
Ultrasound for the Evaluation of Paranasal Sinuses
Radiology | March 23, 1996
Fetal MRI
Radiology | January 1, 2020
Transanal Endoscopic Microsurgery (TEMS)
Surgery | August 1, 2013
Genetic Testing for Neurofibromatosis and Related Disorders
Laboratory | April 1, 2016
Intensity-Modulated Radiotherapy: Central Nervous System Tumors
Therapy | September 1, 2012
MRI Heart
Radiology | January 1, 2020
Focal Treatments for Prostate Cancer
Therapy | June 1, 2015
External Insulin Infusion Pump
Durable Medical Equipment | January 3, 2007
Siltuximab (Sylvant)
Prescription Drug | December 1, 2015
Reproductive Techniques
Ob/Gyn/Reproduction | April 11, 2013
Photodynamic Therapy for Choroidal Neovascularization
Medicine | December 1, 2001
Alternative Treatment Plan
Administrative | January 1, 1979
Chemotherapy Drugs and the Administration by Physicians for the Treatment of Cancer
Prescription Drug | July 1, 2000
Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia
Therapy | July 1, 2013
Laboratory Guideline Policy
Laboratory | January 1, 2020
Genetic Testing for Lipoprotein A Variant as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment
Laboratory | May 1, 2013
Bariatric Surgery
Surgery | July 2, 1996
Vacuum-Assisted Breast Biopsy
Radiology | December 22, 2005
Genetic Testing of Mitochondrial Disorders
Laboratory | July 1, 2014
Reduction Mammaplasty for Breast-Related Symptoms
Surgery | August 1, 2013
Genetic Testing for PTEN Hamartoma Tumor Syndrome
Laboratory | April 1, 2014
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer
Laboratory | August 1, 2013
Hospice Care
Other | March 1, 1995
Pharmacologic Treatment of Hereditary Transthyretin-Mediated Amyloidosis (Onpattro™/Tegsedi™)
Prescription Drug | August 1, 2019
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, and Limb-Girdle Muscular Dystrophies
Laboratory | January 1, 2019
Hepatitis C Testing
Laboratory | January 1, 2016
Keratoprosthesis
Other | March 1, 1996
CT Heart
Radiology | January 1, 2020
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Surgery | December 1, 2009
Dopamine Transporter Imaging With Single Photon Emission Computed Tomography (DAT-SPECT)
Radiology | July 1, 2013
Interlukin 2 as a Treatment for HIV Infection
Prescription Drug | July 1, 1999
Polysomnography for Non‒Respiratory Sleep Disorders
Medicine | August 1, 2015
Genetic Testing for Alzheimer’s Disease
Laboratory | April 1, 2013
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis
Surgery | April 1, 2013
Bowel Management Devices
Medicine | December 1, 2020
Alemtuzumab (Lemtrada)
Prescription Drug | March 1, 2015
Implantation of Intrastromal Corneal Ring Segments
Other | February 1, 2005
Flow Cytometry
Laboratory | January 1, 2016
Biofeedback as a Treatment of Chronic Pain
Medicine | April 1, 1998
ANA/ENA Testing
Laboratory | January 1, 2016
Human Antihemophilic Factor (AHF)
Prescription Drug | January 1, 2021
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
Therapy | June 1, 2010
Extracranial Carotid Angioplasty/Stenting
Surgery | January 1, 2012
Cervical Cancer Screening Technologies With Pap and HPV
Laboratory | July 1, 1998
Speech Therapy
Therapy | June 1, 2013
Methadone Treatment for Opiate Addiction
Mental Health | May 1, 1997
Confocal Laser Endomicroscopy
Medicine | June 1, 2013
Risk-Reducing Mastectomy
Surgery | April 4, 2013
Robotic Assisted Surgery — Reimbursement Policy
Surgery | August 1, 2014
Pathogen Panel Testing
Laboratory | December 1, 2017
Transmyocardial Revascularization
Surgery | May 1, 1997
Implantable Cardioverter Defibrillator (ICD)
Surgery | March 1, 1996
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
Laboratory | June 1, 2014
Hematopoietic Cell Transplantation for Breast Cancer
Therapy | July 1, 2013
Tocilizumab (Actemra®)
Prescription Drug | April 1, 2014
Microsatellite Instability and Tumor Mutational Burden Testing
Laboratory | January 1, 2022
Hypothermia to Prevent/Reduce Hair Loss During Chemotherapy
Medicine | July 1, 2016
Genetic Testing for Germline Mutations of the RET Proto-Oncogene
Laboratory | November 1, 1997
Amniotic Membrane and Amniotic Fluid Injections for Non Ophthalmic Applications
Surgery | July 1, 2015
Isolated Small Bowel Transplant
Surgery | December 1, 1995
Eptinezumab-jjmr (Vyepti™)
Medicine | May 1, 2021
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
Medicine | December 3, 2002
Vagus Nerve Stimulation
Surgery | December 18, 1995
Intensity-Modulated Radiotherapy of the Prostate
Therapy | August 1, 2012
Electrical Bone Growth Stimulation of the Appendicular Skeleton
Surgery | December 1, 1995
Serum Tumor Markers for Malignancies
Laboratory | November 6, 1996
Oxygen Therapy
Durable Medical Equipment | July 1, 1997
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
Therapy | December 13, 2012
Occipital Nerve Stimulation
Surgery | May 1, 2010
Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia
Therapy | July 1, 2013
Orbit, Face, Neck, Sinus MRI
Radiology | January 1, 2021
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Medicine | July 1, 2003
CTA Coronary Arteries (CCTA)
Radiology | July 1, 2011
Preventive Services for Non-Grandfathered (PPACA) Plans: Immunizations
Other | October 1, 2015
MRI Lower Extremity (Ankle, Foot, Knee, Hip, Leg) (Joint and Other Than Joint)
Radiology | January 1, 2020
Extension of Liability
Administrative | May 1, 1989
Lumbar Spinal Procedures
Surgery | March 1, 2017
Cochlear Implant
Surgery | December 1, 1995
Fetal Surgery for Prenatally Diagnosed Malformations
Ob/Gyn/Reproduction | March 1, 1998
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing
Laboratory | July 1, 2019
Zika Virus Risk Assessment
Laboratory | August 1, 2016
Myoelectric Prosthesis Components for the Upper Limb
Durable Medical Equipment | July 1, 2012
Redblood Cell Molecular Testing
Laboratory | September 1, 2020
Treatment of Hyperhidrosis
Therapy | July 24, 1999
Molecular Profiling for Cancers of Unknown Primary Origin
Laboratory | February 1, 2013
Gastric Electrical Stimulation
Surgery | December 1, 2000
Actigraphy
Medicine | March 1, 2005
Partial Left Ventriculectomy
Surgery | April 1, 1998
SPECT/CT Fusion Imaging
Radiology | February 1, 2017
Intraocular Radiation Therapy for Age-Related Macular Degeneration
Other | March 1, 2011
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Medicine | July 1, 1998
Home Uterine Activity Monitoring
Ob/Gyn/Reproduction | December 1, 2013
Plasma Exchange (Plasmapheresis)
Therapy | December 6, 1995
Medication Administration Site of Care
Medicine | September 1, 2017
Intensity-Modulated Radiotherapy of the Breast and Lung
Therapy | August 1, 2012
Home Cardiorespiratory Monitoring
Durable Medical Equipment | March 1, 1996
Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification
Mental Health | October 1, 2002
High-Dose Rate Temporary Prostate Brachytherapy
Therapy | May 1, 2013
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
Therapy | July 1, 2013
Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology)
Laboratory | December 1, 1995
Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus
Therapy | September 1, 2007
Non-Contact Ultrasound Treatment of Wounds
Medicine | November 1, 2008
Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Medicine | July 1, 2003
Cervical Spine Procedures
Surgery | March 1, 2016
Genetic Testing for Polyposis Syndromes
Laboratory | May 1, 2017
Genetic Testing for Ophthalmologic Conditions
Laboratory | January 1, 2014
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Surgery | December 1, 1995
Subtalar Arthroereisis and Subtalar Joint Implant
Durable Medical Equipment | October 1, 2005
Interferential Current Stimulation
Durable Medical Equipment | November 1, 2009
Genetic Testing for Hereditary Hemochromatosis
Laboratory | April 1, 2013
Radioembolization for Primary and Metastatic Tumors of the Liver
Therapy | October 1, 2003
Testing for Autism Spectrum Disorder and Developmental Delay
Laboratory | January 1, 2021
Pancreatic Enzyme Testing for Acute Pancreatitis
Laboratory | August 1, 2018
Incapacitated Dependent Coverage
Other | July 1, 2018
Phone Transfers and Second Requests
Administrative | May 5, 1992
Automated Point-of-Care Nerve Conduction Tests
Medicine | June 1, 2013
Pancreatic Cancer Risk Testing Using Pancreatic Cyst Fluid
Laboratory | June 1, 2009
Heart Transplant
Surgery | July 1, 1996
CD 5 Complement Inhibitors
Prescription Drug | April 1, 2019
Iontophoresis and Phonophoresis
Therapy | May 1, 2001
Contraceptive Management
Medicine | July 1, 2010
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
Surgery | July 1, 1998
Melanoma Vaccines
Medicine | April 1, 1998
Implantable Infusion Pump for Pain and Spasticity
Surgery | November 1, 1996
Wireless Pressure Sensors in Endovascular Aneurysm Repair
Surgery | July 1, 2008
MRI Thoracic Spine
Radiology | January 1, 2020
CT Bone Density Study
Radiology | January 1, 2020
CT Cervical Spine
Radiology | January 1, 2020
CT Abdomen and Pelvis
Radiology | January 1, 2020
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Medicine | July 1, 1999
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
Medicine | December 1, 2014
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
Surgery | January 1, 2011
General Genetic Testing, Somatic Disorders
Laboratory | April 1, 2017
Remote Electrical Neuromodulation for Migraines
Medicine | June 15, 2022
cesar test
Radiology | June 30, 2022
EQE Test 2
Radiology | June 1, 2000
EQE TEST 5
Radiology | June 1, 2007
Dry Hydrotherapy for Chronic Pain Condition
Medicine | July 1, 2022
EQE Test 7 (BW - EDIT (EDIT))
Surgery | August 1, 2008
Change Policy Name 2
Radiology | July 20, 2022
Name change Policy (2)
Radiology | July 20, 2022
Beach Day Today 1
Radiology | July 1, 2010
EQE Test 10 - Hamster Beach Party
Radiology | August 1, 2011
Happy Monday Policy
Radiology | July 25, 2022
Pam Test Policy 1-2
Medicine | August 25, 2022
EQE Test 1
Prescription Drug | July 1, 2022
Prenatal Screening (Genetic)
Laboratory | August 4, 2022
Genetic Markers for Assessing Risk of Cardiovascular Disease
Laboratory | August 3, 2022
Digital Health Technologies: Diagnostic Applications
Durable Medical Equipment | September 1, 2022
Ocriplasmin for Symptomatic Vitreomacular Adhesion
Prescription Drug | September 29, 2013
Medical Management of Obstructive Sleep Apnea Syndrome
Medicine | August 18, 2022
Therapeutic Radiopharmaceuticals for Prostate Cancer
Therapy | October 19, 2022
Skilled Nursing Facility
Medicine | November 1, 2021
Prolia (Denosumab)
Prescription Drug | December 1, 2022
Xgeva (Denosumab)
Prescription Drug | December 1, 2022
Nexviazyme™ (avalglucosidase alfa-ngpt) Injection
Prescription Drug | December 1, 2022
Bimatoprost Implant (Durysta™)
Prescription Drug | December 1, 2022
Nulojix® (belatacept)
Prescription Drug | December 1, 2022
Vabysmo™ (faricimab-svoa)
Prescription Drug | December 1, 2022
Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis
Surgery | November 15, 2022
Annular Closure Devices (e.g., BARRICAID®, XCLOSE®, INCLOSE™)
Durable Medical Equipment | January 1, 2023
Antiemetics
Prescription Drug | July 1, 2022
Nivolumab; Relatlimab-rmbw (Opdualag) injection
Prescription Drug | January 1, 2023
inclisiran (Leqvio®)
Prescription Drug | January 1, 2023
Betibeglogene autotemcel (Zynteglo®) (Intravenous)
Prescription Drug | January 1, 2023
Elivaldogene autotemcel (Skysona) Suspension for Intravenous Infusion
Prescription Drug | January 1, 2023
Axillary Reverse Mapping for Breast Cancer-Related Lymphedema
Surgery | November 21, 2022
Blinatumomab (Blincyto)
Prescription Drug | December 1, 2015
BRINEURA (cerliponase alfa)
Prescription Drug | January 1, 2018