Medical Policies - Alphabetical List

Alphabetical List

Categorical List

Alphabetical List

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A

Abatacept (Orencia®)

Accelerated Breast Irradiation After Breast-Conserving Surgery for Early Stage Breast Cancer and Breast Brachytherapy as Boost with Whole Breast Irradiation

Acoustic Cardiography

Acupuncture and Dry Needling

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies

Adoptive Immunotherapy

Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension

Aerosolized Antibiotics as a Treatment of Chronic Sinusitis

Air Fluidized Beds

Allergy Immunotherapy

Allergy Testing

Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias

Allogeneic Hematopoietic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Allogeneic Pancreas Transplant

Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Alpha-Fetoprotein-L3 for Detection of Hepatocellular (Liver) Cancer

Ambulance and Medical Transport Services

Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions

Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

Analysis of Proteomic Patterns for Early Detection of Cancer

Anesthesia Services

Angelchik™ Anti-Reflux Prosthesis

Antigen Leukocyte Antibody Test

Antineoplaston Therapy and Sodium Phenylbutyrate

Aqueous Shunts and Devices for Glaucoma

Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee

Artificial Intervertebral Disc: Cervical Spine

Artificial Intervertebral Disc: Lumbar Spine

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Athletic Pubalgia Surgery

Attention Deficit/Hyperactivity Disorder

Auditory Brainstem Implant

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Autologous Fat Grafting to the Breast and Adipose-derived Stem Cells

Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas

Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure

Automated Percutaneous and Endoscopic Discectomy

Automated Point-of-Care Nerve Conduction Tests

Autonomic Nervous System Function Testing

Axial Lumbosacral Interbody Fusion

B

Balloon Dilatation of Prostate

Balloon Sinuplasty for Treatment of Chronic Sinusitis

Bariatric Surgery

Baroreflex Stimulation Devices

BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia

Behavioral Health Guidelines

Beta Amyloid Imaging with Positron Emission Tomography (PET) for Alzheimer's Disease

Bevacizumab in Advanced Adenocarcinoma of the Pancreas

Bevacizumab (Avastin) for Oncologic Use

Biochemical Markers of Alzheimer’s Disease

Biofeedback as a Treatment of Chronic Pain

Biofeedback as a Treatment of Fecal Incontinence or Constipation

Biofeedback as a Treatment of Headache

Biofeedback as a Treatment of Urinary Incontinence in Adults

Biofeedback for Miscellaneous Indications

Bioimpedance Devices for Detection and Management of Lymphedema

Biomarker Genes for Detection of Lymph Node Metastases in Breast Cancer

Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

Blepharoplasty (Upper and Lower)

Bone Mineral Density Studies

Bone Morphogenetic Protein

Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

Botulinum Toxin

Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

BRAF Gene Mutation Testing To Select Melanoma Patients for BRAF Inhibitor Targeted Therapy

Brain Natriuretic Peptide (BNP)

Breast Duct Endoscopy

Breast Surgical Procedures/Prosthesis

Bronchial Thermoplasty

C

Canalith Repositioning as a Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Cardiac Applications of PET Scanning

Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

Cardiac Rehabilitation in the Outpatient Setting

Cardiovascular Risk Panels

Catheter Ablation as Treatment for Atrial Fibrillation

Catheter Ablation for Cardiac Arrhythmias

Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)

Cellular Immunotherapy for Prostate Cancer

Cervical Cancer Screening Technologies with Pap and HPV

Cervical Cerclage

Charged-Particle (Proton or Helium Ion) Radiation Therapy

Chelation Therapy for Off-Label Uses

Chemotherapy Drugs and the Administration by Physicians for the Treatment of Cancer

Chiropractic Services

Chromoendoscopy as an Adjunct to Colonoscopy

Chromosomal Microarray Testing for the Evaluation of Early Pregnancy Loss

Chronic Intermittent Intravenous Insulin Therapy (CIIIT)

Chronic Pulmonary Thromboendarterectomy

Clinical Trials for Cancer and Life-Threatening Conditions

Closure Devices for Patent Foramen Ovale and Atrial Septal Defects (ASD)

Cochlear Implant

Cognitive Rehabilitation

Colony-Stimulating Factors

Colorectal Cancer Screening

Composite Tissue Allotransplantation of the Hand and Face

Computed Tomography to Detect Coronary Artery Calcification

Computed Tomography (CT) Perfusion Imaging of the Brain

Computer-aided Detection in Conjunction with Digitized Screen-Film Mammography or Full-Field Digital Mammography

Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast

Computer Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure

Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease

Concurrent Care

Confocal Laser Endomicroscopy

Conjunctival Incision with Posterior Juxtascleral Placement of Anecortave Acetate Depot Suspension

Continent Ileostomy and Urostomy

Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

Continuous Passive Motion (CPM) in the Home Setting

Continuous Renal Replacement Therapies

Contraceptive Management

Contrast Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation

Cooling Devices Used in the Outpatient Setting

Corneal Collagen Cross-linking

Corneal Endothelial Microscopy/Specular Microscopy

Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy

Corporate Administrative/Medical Policy Guidelines (Medical Necessity, Investigational/Experimental)

Correlated Audioelectric Cardiography

Cosmetic/Reconstructive Services

Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation

Cryoablation of Prostate Cancer

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate Tumors or Dermatologic Tumors

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

CT Scanning of the Chest (Thorax) and Chest (Non-Coronary) Computed Tomography Angiography (CTA)

Cutaneous Electrogastrography (EGG)

Cytochrome p450 Genotyping

Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for the Treatment of Pseudomyxoma Peritonei, Peritoneal Carcinomatosis of Gastrointestinal Origin, and Peritoneal Mesothelioma

D

Daily Hemodialysis and Hemodialysis in the Home Setting

Decompression of the Intervertebral Disc Using Laser (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty™)

Deep Brain Stimulation

Dental Services

Dermatologic Applications of Photodynamic Therapy

Detection of Circulating Tumor Cells in the Management of Patients with Cancer

Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology)

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis

Diagnosis and Treatment of Sacroiliac Joint Pain

Diagnosis of Vaginitis including Multitarget PCR Testing

Digital Breast Tomosynthesis

Discarded Drugs/Biologicals - Pharmaceutical Waste

DNA-Based Testing for Adolescent Idiopathic Scoliosis

Donor Leukocyte Infusion for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant

Dopamine Transporter Imaging with Single Photon Emission Computed Tomography (DAT-SPECT)

Doppler Echocardiography

Durable Medical Equipment (DME)

Dynamic Cardiomyoplasty

Dynamic Posturography

Dynamic Spinal Visualization

E

Eculizumab (Soliris®) IV

Electrical Bone Growth Stimulation of the Appendicular Skeleton

Electrical Impedance Scanning of the Breast

Electrical Stimulation for the Treatment of Arthritis

Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

Electrocardiographic Body Surface Mapping

Electrocorticography

Electroencephalograms (EEG)

Electromagnetic Navigation Bronchoscopy

Electrophrenic Pacemaker

Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds

End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema

Endobronchial Brachytherapy

Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer

Endobronchial Valves

Endometrial Ablation

Endoscopic Injection Sclerotherapy for Esophageal Varices

Endoscopic Laser for Gastrointestinal Bleeding

Endoscopic Laser for Tracheobronchial Obstructions

Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus

Endothelial Keratoplasty

Endovascular Grafts for Abdominal Aortic Aneurysms

Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

Endovascular Stent Grafts for Disorders of the Thoracic Aorta

Enhanced External Counterpulsation (EECP)

Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)

Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management (Ductal Lavage and Suction Collection Systems)

Erectile Dysfunction

Erythopoiesis Stimulating Agents and Darbepoetin Alfa (Aranesp)

Esophageal pH Monitoring

Evaluation of Hearing Impairment

External Insulin Infusion Pump

Extracorporeal Immunoadsorption Using Protein A Columns

Extracorporeal Photopheresis

Extracorporeal Shock Wave Lithotripsy for Kidney Stones

Extracorporeal Shock Wave Therapy in the Treatment of Peyronie's Disease

Extracorporeal Shock Wave Treatment for Plantar Faciitis and Other Musculoskeletal Conditions

Extracranial Carotid Angioplasty/Stenting

Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

F

Facet Arthroplasty

Facet Joint Denervation

FDG Using Camera-Based Imaging (FDG-SPECT)

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

Fecal Calprotectin Testing

Fecal Microbiota Transplantation

Fetal Echocardiography

Fetal Fibronectin Enzyme Immunoassay

Fetal RHD Genotyping Using Maternal Plasma

Fetal Surgery for Prenatally Diagnosed Malformations

First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment

Functional Neuromuscular Electrical Stimulation , Robotic-assisted Rehabilitation & Robotic-assisted Orthotics

G

Gamma Interferon Blood Test for Diagnosis of Latent Tuberculosis

Gas Permeable Scleral Contact Lens

Gastric Electrical Stimulation

Gene-Based Tests for Screening, Detection and/or Management of Prostate Cancer

Gene Expression Profiling for Uveal Melanoma

Gene Expression Testing to Predict Coronary Artery Disease

Genetic Cancer Susceptibility Panels Using Next Generation Sequencing

Genetic Testing for Alpha-1 Antitrypsin Deficiency

Genetic Testing for Alpha Thalassemia

Genetic Testing for Cardiac Ion Channelopathies

Genetic Testing for CHARGE Syndrome

Genetic Testing for Dilated Cardiomyopathy

Genetic Testing for Duchenne and Becker Muscular Dystrophy

Genetic Testing for Epilepsy

Genetic Testing for Facioscapulohumeral Muscular Dystrophy

Genetic Testing for Familial Alzheimer’s Disease

Genetic Testing for Familial Cutaneous Malignant Melanoma

Genetic Testing for Fanconi Anemia

Genetic Testing for FLT3 and NPM1 Mutations in Acute Myeloid

Genetic Testing for FMR1 mutations (including Fragile X Syndrome)

Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid

Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Genetic Testing for Hereditary Hearing Loss

Genetic Testing for Hereditary Hemochromatosis

Genetic Testing for Hereditary Pancreatitis

Genetic Testing for Inherited Disorders and Cancer Susceptibility

Genetic Testing for Inherited Thrombophilia

Genetic Testing for Lactase Insufficiency

Genetic Testing for Li-Fraumeni Syndrome

Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment

Genetic Testing for Lynch Syndrome and Other Inherited Intestinal Polyposis Syndromes

Genetic Testing for Macular Degeneration

Genetic Testing for Mental Health Conditions

Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

Genetic Testing for PTEN Hamartoma Tumor Syndrome

Genetic Testing for Rett Syndrome

Genetic Testing for Statin-Induced Myopathy

Genetic Testing for Tamoxifen Treatment

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

Genetic Testing for Warfarin Dose

Genetic Testing of CADASIL Syndrome

Genetic Testing of Mitochondrial Disorders

Genetic Testing, Including Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for Prenatal Evaluation and the Evaluation of Children With Developmental Delay/Intellectual Disability or Autism Spectrum Disorder

Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm

Golimumab (Simponi)

H

H-wave Electrical Stimulation

Heart Transplant

Heart/Lung Transplant

Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia

Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia

Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases

Hematopoietic Stem-Cell Transplantation for Breast Cancer

Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia

Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma

Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer

Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma

Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Hematopoietic Stem-Cell Transplantation in the Treatment of Germ-Cell Tumors

Hepatitis A and B Vaccination

Hereditary Angioedema Drug Therapy

High-Dose Rate Temporary Prostate Brachytherapy

High-Sensitivity C-Reactive Protein and Peripheral Arterial Tonometry

High Intensity Focused Ultrasound for the Treatment of Prostate Cancer

Hip Resurfacing

HIV Genotyping and Phenotyping

Home Apnea Monitors

Home Phototherapy for Neonatal Jaundice

Home Prothrombin Time Monitoring

Home Spirometry

Home Uterine Activity Monitoring

Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease

Hospital Medical Services (Inpatient and Observation) and Consultation

Human Antihemophilic Factor (AHF)

Human Growth Hormone

Human Leukocyte Antigen (HLA) Testing for Celiac Disease

Human Papillomavirus (HPV) Vaccines

Hyperbaric Oxygen Pressurization (HBO2)

Hysteroscopic Placement of Micro-inserts in the Fallopian Tubes as a Form of Permanent Sterilization

I

Identification of Microorganisms Using Nucleic Acid Probes

Ilizarov Bone-Lengthening Procedure

Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis

Immune Cell Function Assay

Immune Globulin Therapy

Immune Prophylaxis for Respiratory Syncytial Virus

Immunochemical Fecal Occult Blood Testing

Implantable Bone Conduction and Bone Anchored Hearing Aids

Implantable Cardioverter Defibrillator (ICD)

Implantable Hormone Pellets for Females

Implantable Infusion Pump

Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery

Implantation of Intrastromal Corneal Ring Segments

In Vitro Chemoresistance and Chemosensitivity Assays

Influenza Vaccine

Infrared Coagulation for Hemorrhoids

Ingestible pH and Pressure Capsule

Inhaled Nitric Oxide

Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

Injectable Clostridial Collagenase for Fibroproliferative Disorders

Inpatient Intestinal Rehabilitation Therapy

Inpatient Rehabilitation

Insulin Potentiation Therapy

Intensity-Modulated Radiation Therapy (IMRT) of the Prostate

Intensity-Modulated Radiation Therapy (IMRT): Abdomen and Pelvis

Intensity-Modulated Radiation Therapy (IMRT): Cancer of the Head and Neck or Thyroid

Intensity Modulated Radiation Therapy (IMRT) of the Breast and Lung

Intensity Modulated Radiation Therapy (IMRT): Central Nervous System Tumors

Interferential Current Stimulation

Interlukin 2 as a Treatment for HIV Infection

Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

Interspinous Fixation (Fusion) Devices

Interventions for Progressive Scoliosis

Intra-Articular Hyaluronan Injections for Osteoarthritis

Intracardiac Electrophysiologic Studies

Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain

Intracellular Micronutrient Analysis

Intracoronary Doppler Ultrasound

Intradialytic Parenteral Nutrition

Intraocular Radiation Therapy for Age-Related Macular Degeneration

Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)

Intraoperative Radiation Therapy

Intratympanic Injections of a Pharmacologic Agent for the Treatment of Meniere's Disease or Sudden Hearing Loss

Intravascular Brachytherapy for Preventing and Managing Restenosis after Percutaneous Transluminal Angioplasty (PTA)

Intravascular Ultrasound Imaging of Coronary and Non-Coronary Arteries

Intravenous Anesthetics for the Management of Chronic Neuropathic Pain

Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease

Intravenous or Subcutaneous Histamine Therapy

Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions

Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions

Intravitreal Corticosteroid Implants

Iontophoresis and Phonophoresis

Ipilimumab (Yervoy)

Islet Cell Transplantation

Isolated Limb Perfusion/Infusion for Malignant Melanoma

Isolated Small Bowel Transplant

J

JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms

K

Keratoprosthesis

Ketogenic Diet as a Treatment of Refractory Epilepsy

Kidney Transplant

KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

Knee Braces, Orthopaedic Casts, Splints

KRAS Mutation Analysis in Non-Small Cell Lung Cancer (NSCLC)

KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer

L

M

Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)

Magnetic Resonance Angiography of Vessels of the Head, Neck, Abdomen, Pelvis and Lower Extremity

Magnetic Resonance Angiography (MRA) of the Chest (excluding the heart)

Magnetic Resonance Cholangiopancreatography (MRCP)

Magnetic Resonance Spectroscopy

Magnetoencephalography/Magnetic Source Imaging

Manipulation Under Anesthesia

Maternity/Obstetrical Care Benefits

Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders

Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk

Measurement of Long-Chain Omega-3 Fatty Acids in Red Blood Cell Membranes as a Cardiac Risk Factor

Measurement of Serum Antibodies to Infliximab and Adalimumab

Measurement of Serum Intermediate Density Lipoproteins (Remnant-Like Particles)

Measurement of Thromboxane Metabolites for Aspirin Resistance

Mechanical Embolectomy for Treatment of Acute Stroke

Mechanical Insufflation-Exsufflation as an Expiratory Muscle Aid

Mechanical Stretching Devices for Contracture and Joint Stiffness

Melanoma Vaccines

Meniscal Allografts and Other Meniscal Implants

Methadone Treatment for Opiate Addiction

Microarray-based Gene Expression Analysis for Prostate Cancer Management

Microarray-Based Gene Expression Testing for Cancers of Unknown Primary

Microprocessor-Controlled Prosthetic for the Lower Limb

Microwave Tumor Ablation

Minimally Invasive Coronary Artery Bypass Graft Surgery

Minimally Invasive Hip and Knee Arthroplasty

Miscellaneous (Non-cardiac, Non-oncologic) Applications of Positron Emission Tomography (PET)

Molecular Markers in Fine Needle Aspirates of the Thyroid

Molecular Panel Testing of Cancers to Identify Targeted Therapies

Monitoring of Regional Cerebral Blood Flow Using an Implanted Cerebral Thermal Perfusion Probe

MRI-Guided Focused Ultrasound (MRgFUS)

MRI of the Breast

Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes

Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease

Multigene Expression Assay for Predicting Recurrence in Colon Cancer

Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure

Myoelectric Prosthesis Components for the Upper Limb

N

Natalizumab (Tysabri®)

Negative Pressure Wound Therapy in the Outpatient Setting

Nerve Fiber Density Testing

Nerve Graft in Association with Radical Prostatectomy

Neuromuscular Electrical Stimulation (NMES)

Newer Oral Anticoagulants

Non-contact Ultrasound Treatment of Wounds

Non-Pharmacologic Treatment of Rosacea

Noncontact Radiant Heat Bandage for the Treatment of Wounds

Noninvasive Prenatal Testing for Trisomy 21 Using Cell-Free Fetal DNA

Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease

O

Occipital Nerve Stimulation

Occlusion of Uterine Arteries Using Transcatheter Embolization

Occupational Therapy

Ocriplasmin for Symptomatic Vitreomacular Adhesion

Octreotide Acetate (Sandostatin)

Ocular Photoscreening in the Primary Care Physician's Office as a Screening Tool to Detect Amblyogenic Factors

Omalizumab (Xolair®)

Oncologic Applications of Interleukin-2 (Aldesleukin) When Used as Monotherapy

Oncologic Applications of PET Scanning

Oncologic uses of Interferon Therapy

Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Other Related Procedures)

Ophthalmologic Techniques for Evaluating Glaucoma

Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification

Optical Coherence Tomography for Imaging of Coronary Arteries

Optical Coherence Tomography of the Anterior Eye Segment

Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy

Oral Screening, Lesion Identification Systems and Genetic Screening

Orthodontic Treatment

Orthognathic Surgery

Orthopedic Applications of Stem-Cell Therapy

Orthoptic Training for the Treatment of Vision or Learning Disabilities

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders

Outpatient Pulmonary Rehabilitation

Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

P

Pain Management Services (Chronic Pain and Rehabilitation Therapies)

Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain

Partial Coherence Interferometry as a Technique to Measure the Axial Length of the Eye

Partial Left Ventriculectomy

Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss

PathFinderTG® Molecular Testing

Patient-Controlled Analgesia

Pegloticase (Krystexxa)

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Pembrolizumab (Keytruda)

Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation

Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)

Percutaneous Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty

Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Percutaneous Treatment of Fracture Non-Unions or Bone Defects with Autologous Bone Marrow with or without Demineralized Bone Matrix (DBM)

Percutaneous Vertebroplasty and Sacroplasty

Peripheral Subcutaneous Field Stimulation

Periureteral Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR)

Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

Pertuzumab for Treatment of Malignancies

PET Scanning in Oncology to Detect Early Response during Treatment

Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines

Photocoagulation of Macular Drusen

Photodynamic Therapy for Subfoveal Choroidal Neovascularization

Phototherapeutic Keratectomy

Physical Therapy

Placental and Umbilical Cord Blood as a Source of Stem Cells

Plasma Exchange (Plasmapheresis)

Plasma HIV-1 RNA Quantification for HIV-1 Infection

Plugs for Fistula Repair

Pneumatic Compression Pumps for Treatment of Lymphedema

Positional Magnetic Resonance Imaging (MRI)

Positron Emission Mammography (PEM)

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

Prenatal Genetic and Chromosomal Metabolic Testing

Preventive Services for Non-Grandfathered (PPACA) Plans: Behavioral Counseling for Prevention

Preventive Services for Non-Grandfathered (PPACA) Plans: USPSTF recommended services

Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia

Progesterone Therapy as a Technique to Reduce Preterm Delivery in High-Risk Pregnancies

Prophylactic Mastectomy

Proteomics-Based Testing Related to Ovarian Cancer

Pulsed Irrigation of Fecal Impaction

Q

Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers

Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder

Quantitative Sensory Testing

R

Radiation Oncology Services

Radioactive Seed Localization of Nonpalpable Breast Lesions

Radioembolization for Primary and Metastatic Tumors of the Liver

Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

Radiofrequency Ablation of Primary or Metastatic Liver Tumors

Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension

Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) Using In-111 Satumomab Pendetide (OncoScint) or Tc-99m Arcitumomab (IMMU-4, CEA-Scan)

Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) Using Technetium-99m Nofetumomab Merpentan (Verluma)

Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) With Indium-111 Capromab Pendetide (Prostascint®) for Prostate Cancer

Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma

Radiopharmaceutical Agents and Other In Vivo Diagnostic Aids

Rapid Flu Tests in the Outpatient Setting

Real-Time Intra-Fraction Motion Management During Radiation Therapy

Recombinant and Autologous Platelet-Derived Growth Factors (PDGF) as a Treatment of Wound Healing and Other Miscellaneous Conditions

Reduction Mammaplasty for Breast-Related Symptoms

Registered Nurses Practicing in Extended Roles

Repository Corticotropin Injection

Reproductive Techniques

Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy

Retinal Prosthesis

Retinal Telescreening for Diabetic Retinopathy

Reverse Shoulder Arthroplasty

Robotic Assisted Surgery - Reimbursement Policy

Ross Pulmonary Autograft

S

Sacral Nerve Neuromodulation/Stimulation

Salivary Estriol as Risk Predictor for Preterm Labor

Salivary Hormone Testing for Menopause and Aging

Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

Scintigraphy of Acute Deep Venous Thrombus

Scintigraphy Using Indium-111 Pentetreotide (Octreoscan)

Scintimammography and Gamma Imaging of the Breast and Axilla

Screening for Lung Cancer Using CT Scanning

Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy

Semi-Implantable Middle Ear Hearing Aid for Moderate to Severe Sensorineural Hearing Loss

Sensory Integration Therapy

Sensory Stimulation for Coma Patients

Serologic Diagnosis of Celiac Disease

Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease

Serum Biomarker Human Epididymis Protein 4 (HE4)

Serum Biomarker Tests for Multiple Sclerosis

Serum Holo-Transcobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status

Serum Tumor Markers for Malignancies

Signal-Averaged Electrocardiography

Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy and Miscellaneous Musculoskeletal Conditions

Small Bowel/Liver and Multivisceral Transplant

Spinal Cord Stimulation

Stem-cell Therapy for Peripheral Arterial Disease

Stereotactic Electroencephalography

Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson’s Disease

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Stimulation of the Sacral Anterior Root Combined with Posterior Sacral Rhizotomy in Patients with Spinal Cord Injury

Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy

Subtalar Arthroereisis and Subtalar Joint Implant

Suprachoroidal Delivery of Pharmacologc Agents

Surgical and Ablative Treatments for Chronic Headaches

Surgical Guidelines (Secondary, Multiple Procedures, Co-Surgeons, Assistant Surgeons, Stand- By Physicians, Microsurgery/Microdissection)

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Surgical Treatment of Bilateral Gynecomastia

Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)

Surgical Treatment of Femoroacetabular Impingement

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

Surgical Ventricular Restoration

Sympathetic Therapy for the Treatment of Pain

Systems Pathology in Prostate Cancer

T

T-Wave Alternans

Temporary Prostatic Stent

Temporomandibular Joint Dysfunction

Testosterone Replacement Therapies

Thermal Capsulorrhaphy as a Treatment of Joint Instability

Thoracic-Lumbo-Sacral Orthosis with Pneumatics

Threshold Electrical Stimulation as a Treatment of Motor Disorders

Tissue Pressure Measurement

Tocilizumab (Actemra®)

Topographic Brain Mapping

Total Ankle Replacement

Total Artificial Hearts and Implantable Ventricular Assist Devices

Total Parenteral Nutrition and Enteral Nutrition in the Home

Transanal Endoscopic Microsurgery (TEMS)

Transanal Radiofrequency Treatment of Fecal Incontinence

Transcatheter Aortic-Valve Implantation for Aortic Stenosis

Transcatheter Arterial Chemoembolization (TACE) to Treat Primary or Metastatic Liver Malignancies

Transcatheter Closure of Patent Ductus Arteriosus

Transcatheter Mitral Valve Repair

Transcatheter Pulmonary Valve Implantation

Transcoronary Ablation of Septal Hypertrophy (TASH)

Transcranial Doppler Ultrasound

Transcranial Magnetic Stimulation for Depression and Other Neuropsychiatric Disorders

Transcutaneous Electrical Nerve Stimulation (TENS)

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease

Transfusion Therapy for Hemolytic Disease of the Fetus and the Newborn

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Transmyocardial Revascularization

Transpupillary Thermotherapy for Treatment of Choroidal Neovascular Conditions

Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease

Transurethral Microwave Thermotherapy

Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

Treatment of Uterine Fibroids

Treatment of Hepatitis C with Interferon and/or Ribavirin

Treatment of Hyperhidrosis

Treatment of Tinnitus

Treatment of Twin-Twin Transfusion Syndrome with Amnioreduction and/or Fetoscopic Laser Therapy

Treatment of Varicose Veins/Venous Insufficiency

Tumor-Treatment Fields Therapy for Glioblastoma

U

Ultrafiltration in Decompensated Heart Failure

Ultrasonographic Evaluation of Skin Lesions

Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis

Ultrasound Accelerated Fracture Healing Device

Ultrasound for the Evaluation of Paranasal Sinuses

Unicompartmental and Bicompartmental Knee Arthroplasties

Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee

Urea Breath Test for Diagnosis of Helicobacter Pylori

Urinary Tumor Markers for Bladder Cancer

Urine Drug Testing in the Management of Chronic Non-Cancer Pain

Use of Common Genetic Variants (single nucleotide polymorphisms) to Predict Risk of Nonfamilial Breast Cancer

Use of Magnetic Resonance Imaging to Monitor Integrity of Silicone Gel-Filled Breast Implants

Uses of Monoclonal Antibodies for the Treatment of Non-Hodgkin Lymphoma, including Chronic Lymphocytic Leukemia, and Acute Myeloid Leukemia in the Non-Hematopoietic Stem-Cell Transplant Setting

V

Vacuum-Assisted Breast Biopsy

Vacuum Therapy as a Treatment for Female Sexual Dysfunction

Vagus Nerve Stimulation

Vasectomy Using a Polymeric Clip

Vectra DA Blood Test for Rheumatoid Arthritis

Vertebral Axial Decompression

Vertebral Fracture Assessment with Densitometry

Vertical Expandable Prosthetic Titanium Rib

Videofluoroscopic Evaluation of Velopharyngeal Dysfunction

Virtual Colonoscopy/CT Colonography

Viscocanalostomy and Canaloplasty

Visual and Auditory Evoked Potentials

W

Wearable Cardioverter-Defibrillators

Whole Body Computed Tomography Scan as a Screening Test

Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition

Whole Exome and Whole Genome Sequencing for Diagnosis of Patients With Suspected Genetic Disorders

Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon

Wireless Pressure Sensors in Endovascular Aneurysm Repair

Work Hardening Programs

X

Y

Z