Medical Policies - Alphabetical List

Alphabetical List

Categorical List

Alphabetical List

All | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

Abatacept (Orencia®)

ABDOMEN MRA (Angiography)

Abdominoplasty, Panniculectomy and Lipectomy

Ablation of Peripheral Nerves to Treat Pain

Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

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

Acoustic Cardiography

Acupuncture and Dry Needling

Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

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

Adoptive Immunotherapy

Aducanumab for Alzheimer Disease

Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension

Aerosolized Antibiotics as a Treatment of Chronic Sinusitis

Air Fluidized Beds

Alcohol Injections for Treatment of Peripheral Neuromas

Alemtuzumab (Lemtrada)

Allergen Testing

Allergy Immunotherapy

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

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

Allogeneic Pancreas Transplant

Allograft Injection for Degenerative Disc Disease

Ambulance and Medical Transport Services

Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

Ambulatory or Video Electroencephalogram (EEG) Monitoring, Including Digital Analysis of Electroencephalogram

Amniotic Membrane and Amniotic Fluid Injections for Non Ophthalmic Applications

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

ANA/ENA Testing

Anesthesia Services

Angelchik™ Anti-Reflux Prosthesis

Antineoplaston Therapy and Sodium Phenylbutyrate

Aqueous Shunts and Devices for Glaucoma

Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee

Artificial Pancreas Device Systems

Auditory Brainstem Implant

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

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 Point-of-Care Nerve Conduction Tests

Autonomic Nervous System Testing

Avelumab (Bavencio®)

Axial Lumbosacral Interbody Fusion

B

Balloon Dilation of the Eustachian Tube

Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis

Bariatric Surgery

Baroreflex Stimulation Devices

BCR-ABL1 Testing

Belinostat (Beleodaq)

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

Bevacizumab in Advanced Adenocarcinoma of the Pancreas

Bevacizumab (Avastin) for Oncologic Use

Bezlotoxumab (Zinplava)

Biochemical Markers of Alzheimer Disease and Dementia

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 Testing for Multiple Sclerosis and Related Neurologic Diseases

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

Blepharoplasty (Upper and Lower)

Blinatumomab (Blincyto)

Bone Mineral Density Studies

Bone Morphogenetic Protein

Bone Turnover Markers Testing

Botulinum Toxin

Bowel Management Devices

Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

Brain Natriuretic Peptide (BNP)

Brain (Head) MRA/MRV

Brain (Head) MRS

Breast Duct Endoscopy

Breast Surgical Procedures/Prosthesis

Brexanolone for Postpartum Depression

BRINEURA (cerliponase alfa)

Bronchial Thermoplasty

Bronchial Valves

Bulking Agents for the Treatment of Vocal Cord Paralysis

Buprenorphine Implant for Treatment of Opioid Dependence

C

Cardiac Applications of PET Scanning

Cardiac Biomarkers for Myocardial Infarction

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

Cardiac Rehabilitation in the Outpatient Setting

Cardiovascular Disease Risk Assessment

Catheter Ablation as Treatment for Atrial Fibrillation

Catheter Ablation for Cardiac Arrhythmias

CD 5 Complement Inhibitors

Celiac Disease Testing

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

Cellular Immunotherapy for Prostate Cancer

Cemiplimab-rwlc (Libtayo®)

Cerebral Perfusion Analysis CT

Cervical Cancer Screening Technologies with Pap and HPV

Cervical Spine Procedures

Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

Chelation Therapy for Off-Label Uses

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

Chimeric Antigen Receptor Therapy for Hematologic Malignancies

Chimeric Antigen Receptor Therapy for Multiple Myeloma

Chiropractic Services

Chromoendoscopy as an Adjunct to Colonoscopy

Chromosomal Microarray

Chronic Intermittent Intravenous Insulin Therapy (CIIIT)

Chronic Pulmonary Thromboendarterectomy

Cimzia® (certolizumab pegol)

Clinical Trials

Cluneal Nerve Block For Treatment Of Low Back Pain

Cochlear Implant

Cognitive Rehabilitation

Colorectal Cancer Screening

Composite Tissue Allotransplantation of the Hand and Face

Computed Tomography to Detect Coronary Artery Calcification

Computer-Assisted Navigation for 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

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

Continuous Passive Motion (CPM) in the Home Setting

Contraceptive Management

Cooling Devices Used in the Outpatient Setting

Corneal Collagen Cross-linking

Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy

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

Cosmetic/Reconstructive Services

COVID-19 Testing

Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation

Crizanlizumab-tmca (Adakveo)

Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

CT Abdomen and Pelvis

CT Angiography, Abdomen

CT Angiography, Abdomen and Pelvis

CT Angiography, Abdominal Arteries

CT Angiography, Chest (non coronary)

CT Angiography, Head/Brain

CT Angiography, Neck

CT Angiography, Pelvis

CT Angiography, Upper Extremity

CT Bone Density Study

CT Cervical Spine

CT Chest (Thorax)

CT Lower Extremity (Ankle, Foot, Hip or Knee)

CT Lumbar Spine

CT Soft Tissue Neck

CT Thoracic Spine

CT Upper Extremity

CT (Virtual) Colonoscopy

CTA Coronary Arteries (CCTA)

Cutaneous Electrogastrography (EGG)

D

Daily Hemodialysis and Hemodialysis in the Home Setting

Daratumumab (Darzalex®) Injection

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

Deep Brain Stimulation

Dermatologic Applications of Photodynamic Therapy

Desensitization Treatment for Peanut Allergies

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 Non-Surgical Sacroiliac Joint Pain

Diagnosis of Vaginitis including Multi-target PCR Testing

Diagnostic Testing of Influenza

Diagnostic Testing of Iron Homeostasis & Metabolism

Diagnostic Testing of Most Common Sexually Transmitted Infections

Digital Breast Tomosynthesis

Discarded Drugs/Biologicals - Pharmaceutical Waste

DNA Ploidy Cell Cycle Analysis

Donor Lymphocyte Infusion for Malignancies Treated With an Allogeneic Hematopoietic Cell Transplant

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

Dry Needling of Trigger Point Injections for Myofascial Pain

Durable Medical Equipment (DME)

Dynamic Cardiomyoplasty

Dynamic Posturography

Dynamic Spinal Visualization

E

Electrical and Electromagnetic Stimulation for the Treatment of Arthritis

Electrical Bone Growth Stimulation of the Appendicular Skeleton

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

Electromagnetic Navigation Bronchoscopy

Electronic Brachytherapy for Nonmelanoma Skin Cancer

Electrophrenic Pacemaker

Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds

Emapalumab-lzsg (Gamifant)

Endobronchial Brachytherapy

Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer

Endoscopic Injection Sclerotherapy for Esophageal Varices

Endoscopic Laser for Gastrointestinal Bleeding

Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus

Endothelial Keratoplasty

Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

Endovascular Stent Grafts for Disorders of the Thoracic Aorta

Endovascular Therapies for Extracranial Vertebral Artery Disease

Enhanced External Counterpulsation (EECP)

Enteral Carbidopa and Levodopa Intestinal Gel Suspension

Enteral Feeding In-Line Cartridge (EFIC™)/Immobilized Lipase Cartridge/Relizorb™

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

Eptinezumab-jjmr (Vyepti™)

Erectile Dysfunction

Erythopoiesis Stimulating Agents and Darbepoetin Alfa (Aranesp)

Esketamine Nasal Spray for Treatment-Resistant Depression

Esophageal Pathology Testing

Esophageal pH Monitoring

Eteplirsen for Duchenne Muscular Dystrophy

Evaluation of Hearing Impairment

Extended-Release Injectable (Sublocade)

External Insulin Infusion Pump

Extracorporeal Immunoadsorption Using Protein A Columns

Extracorporeal Membrane Oxygenation for Adult Conditions

Extracorporeal Photopheresis

Extracorporeal Shock Wave Treatment for Plantar Faciitis and Other Musculoskeletal Conditions

Extracranial Carotid Angioplasty/Stenting

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

F

Facet Arthroplasty

FDG Using Camera-Based Imaging (FDG-SPECT)

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Fecal Microbiota Transplantation

Fetal Surgery for Prenatally Diagnosed Malformations

Fibromyalgia Testing

Focal Treatments for Prostate Cancer

Fractional Flow Reserve CT

Functional MRI Brain

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

G

Gamma-glutamyl Transferase

Gas Permeable Scleral Contact Lens

Gastric Electrical Stimulation

Gender Reassignment Surgery

Gene Expression Profiling and Protein Biomarkers for Prostate Cancer

Gene Expression Testing for Breast Cancer Prognosis

Gene Therapy for Inherited Retinal Dystrophy/Luxturna™

General Genetic Testing, Germline Disorders

General Genetic Testing, Somatic Disorders

General Inflammation Testing

Genetic Cancer Susceptibility Panels Using Next Generation Sequencing

Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma

Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma

Genetic Testing for Acute Myeloid Leukemia

Genetic Testing for Adolescent Idiopathic Scoliosis

Genetic Testing for Alpha- and Beta-Thalassemia

Genetic Testing for Alzheimer’s Disease

Genetic Testing for CHARGE Syndrome

Genetic Testing for Connective Tissue Disorders

Genetic Testing for Cystic Fibrosis

Genetic Testing for Duchenne, Becker, Facioscapulohumeral, and Limb-Girdle Muscular Dystrophies

Genetic Testing for Epilepsy

Genetic Testing for Familial Cutaneous Malignant Melanoma

Genetic Testing for Fanconi Anemia

Genetic Testing for FMR1 mutations (including Fragile X Syndrome)

Genetic Testing for Germline Mutations of the RET Proto-Oncogene

Genetic Testing for Hereditary Hearing Loss

Genetic Testing for Hereditary Hemochromatosis

Genetic Testing for Hereditary Pancreatitis

Genetic Testing for Heterozygous Familial Hypercholesterolemia

Genetic Testing for Inherited Cardiomyopathies and Channelopathies

Genetic Testing for Lactase Insufficiency

Genetic Testing for Li-Fraumeni Syndrome

Genetic Testing for Lipoprotein A Variant as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment

Genetic Testing for Mental Health Conditions

Genetic Testing for Neurodegenerative Disorders

Genetic Testing for Neurofibromatosis and Related Disorders

Genetic Testing for Ophthalmologic Conditions

Genetic Testing for Polyposis Syndromes

Genetic Testing for PTEN Hamartoma Tumor Syndrome

Genetic Testing for Rett Syndrome

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

Genetic Testing of CADASIL Syndrome

Genetic Testing of Mitochondrial Disorders

Genicular Nerve Blocks and Ablation for Chronic Knee Pain

Golimumab (Simponi) for subcutaneous use

H

H-wave Electrical Stimulation

Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery

Heart Transplant

Heart/Lung Transplant

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

Hematopoietic Cell Transplantation for Breast Cancer

Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer

Hematopoietic Cell Transplantation for Hodgkin Lymphoma

Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

Hematopoietic Cell Transplantation for Primary Amyloidosis

Hematopoietic Cell Transplantation for Solid Tumors of Childhood

Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia

Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors

Hematopoietic Colony-Stimulating Factors (CSFs)

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 Acute Myeloid Leukemia

Hematopoietic Stem Cell Transplantation for Autoimmune Diseases

Hepatitis C testing

Hereditary Angioedema Drug Therapy

High-Dose Rate Temporary Prostate Brachytherapy

Hip Resurfacing

HIV Genotyping and Phenotyping

Home Cardiorespiratory Monitoring

Home Health Services Policy

Home Phototherapy for Neonatal Jaundice

Home Prothrombin Time Monitoring

Home Spirometry

Home Uterine Activity Monitoring

Hospital Medical Services (Inpatient and Observation) and Consultation

Human Antihemophilic Factor (AHF)

Human Growth Hormone

Human Papillomavirus (HPV) Vaccines

Hyperbaric Oxygen Therapy

HYPERTHERMIA With Radiation

Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

Hypothermia to Prevent/Reduce Hair Loss During Chemotherapy

I

Identification of Microorganisms Using Nucleic Acid Probes

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

Imfinzi (durvalumab)

Immune Cell Function Assay

Immune Globulin Therapy

Immune Prophylaxis for Respiratory Syncytial Virus

Immunopharmacologic Monitoring of Therapeutic Serum Antibodies

Implantable Bone Conduction and Bone Anchored Hearing Aids

Implantable Cardioverter Defibrillator (ICD)

Implantable Hormone Pellets for Females

Implantable Infusion Pump for Pain and Spasticity

Implantation of Intrastromal Corneal Ring Segments

In Vitro Chemoresistance and Chemosensitivity Assays

Incapacitated Dependent Coverage

InflammaDry Test

Influenza Vaccine

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): Abdomen and Pelvis

Intensity-Modulated Radiotherapy of the Breast and Lung

Intensity-Modulated Radiotherapy of the Prostate

Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

Intensity-Modulated Radiotherapy: Central Nervous System Tumors

Interferential Current Stimulation

Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment

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 Ischemia Monitoring

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

Intraoperative Radiotherapy

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

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Intravenous Antibiotic Therapy for Lyme Disease

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

K

Keratoprosthesis

Kidney Transplant

Knee Braces, Orthopaedic Casts, Splints

KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer

L

Laboratory Guideline Policy

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Laboratory/Pathology Services

Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids

Laser-Assisted Tonsillectomy

Laser Treatment of Active Acne

Laser Treatment of Onychomycosis

Laser Treatment of Port Wine Stain

Light Therapy for Dermatologic Conditions

Lipid Apheresis

Liver Transplant and Combined Liver-Kidney Transplant

Local or Whole Body Hyperthermia

Low-Level Laser Therapy

Low Intensity Pulsed Ultrasound Fracture Healing Device

Lower Extremity CTA/CTV

LOWER EXTREMITY MRA/MRV

Lumasiran for Primary Hyperoxaluria Type 1

Lumbar Spinal Procedures

Lung and Lobar Lung Transplant

Lung Volume Reduction Surgery for Severe Emphysema

Lyme Disease Testing

Lynch Syndrome Testing

Lysis of Epidural Adhesions

M

Magnetic Resonance‒Guided Focused Ultrasound

Magnetoencephalography/Magnetic Source Imaging

Manipulation Under Anesthesia

Maternity/Obstetrical Care Benefits

Measurement of Thromboxane Metabolites for Aspirin Resistance

Medical Policy Development and Review

Medical Records Documentation Standards

Medication Administration Site of Care

Melanoma Vaccines

Meniscal Allografts and Other Meniscal Implants

Mental Health Services

Mepolizumab (Nucala®)

Metabolite Markers of Thiopurines Testing

Methadone Treatment for Opiate Addiction

Microprocessor-Controlled Prosthetic for the Lower Limb

Microwave Tumor Ablation

Minimal Residual Disease

Minimally Invasive Coronary Artery Bypass Graft Surgery

Minimally Invasive Hip and Knee Arthroplasty

Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

Mitomycin for Pyelocalyceal Solution (Jelmyto)

Molecular Analysis for Gliomas

Molecular Markers in Fine Needle Aspirates of the Thyroid

Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy

Molecular Profiling for Cancers of Unknown Primary Origin

Molecular Testing for Chronic Heart Failure and Heart Transplant

Molecular Testing of Pulmonary Specimens

Monoclonal Antibody Therapies for Migraine Prevention

MR Angiography Chest

MR Angiography Spinal Canal

MR Angiography Upper Extremity

MRI Bone Marrow

MRI Brain (includes Internal Auditory Canal)

MRI Cervical Spine

MRI Chest (Thorax)

MRI Lower Extremity (Ankle, Foot, Knee, Hip, Leg) (Joint and other than joint)

MRI Lumbar Spine

MRI MRCP Abdomen

MRI Temporomandiublar Joint (TMJ)

MRI Thoracic Spine

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

Multigene Expression Assay for Predicting Recurrence in Colon Cancer

Multispectral Digital Skin Lesion Analysis

Mutation Analysis in Myeloproliferative Neoplasms

Myocardial Perfusion Imaging (Nuc Card)

Myocardial Strain Imaging

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 with Radical Prostatectomy

Neuromuscular Electrical Stimulation (NMES)

NEUTRON BEAM THERAPY (NBT)

Nivolumab (Opdivo)

Non-contact Ultrasound Treatment of Wounds

Non-Pharmacologic Treatment of Rosacea

Noncontact Radiant Heat Bandage for the Treatment of Wounds

Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease

Nusinersen for Spinal Muscular Atrophy

O

Occipital Nerve Stimulation

Occlusion of Uterine Arteries Using Transcatheter Embolization

Occupational Therapy

Ocrelizumab (Ocrevus™)

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

Olaratumab (Lartruvo)

Omalizumab (Xolair®)

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

Oncologic Applications of PET Scanning

Oncologic uses of Interferon Therapy

Onychomycosis Testing

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

Ophthalmologic Techniques That Evaluate the Posterior Segment for 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

Oral Screening, Lesion Identification Systems and Genetic Screening

ORBIT, FACE, NECK, SINUS MRI

Orthodontic Treatment

Orthognathic Surgery

Orthopedic Applications of Platelet-Rich Plasma

Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)

Orthoptic Training for the Treatment of Vision or Learning Disabilities

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

Outpatient Pulmonary Rehabilitation

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

P

Pain Management Services (Chronic Pain and Rehabilitation Therapies)

Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid

Pancreatic Enzyme Testing for Acute Pancreatitis

Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain

Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing

Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)

Paravertebral Facet Joint Injections/Blocks

PARSABIV™ (etelcalcetide)

Partial Left Ventriculectomy

Pathogen Panel Testing

Patient-Controlled Analgesia

Patient-Controlled End of Range Motion Stretching Devices

Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty

Pegloticase (Krystexxa)

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

PELVIS MRAngiography

Pembrolizumab (Keytruda)

Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation

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

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty

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

Percutaneous Tibial Nerve Stimulation

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

Pharmacogenetic Testing

Pharmacologic Treatment of Hereditary Transthyretin-Mediated Amyloidosis (Onpattro™/Tegsedi™)

Photocoagulation of Macular Drusen

Photodynamic Therapy for Choroidal Neovascularization

Phototherapeutic Keratectomy

Physical Therapy

Placental and Umbilical Cord Blood as a Source of Stem Cells

Plasma Exchange (Plasmapheresis)

Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection

Plugs for Fistula Repair

Pneumatic Compression Pumps for Treatment of Lymphedema

Polysomnography for Non‒Respiratory Sleep Disorders

Positional Magnetic Resonance Imaging (MRI)

Positron Emission Mammography (PEM)

Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

Pre-implantation Genetic Testing

Prenatal Genetic and Chromosomal Metabolic Testing

Prenatal Screening

Prenatal Screening for Fetal Aneuploidy

Prescription Digital Therapeutics for Substance Abuse

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

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

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

Preventive Services for Non Grandfathered (PPACA) Plans: Immunizations

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

Proteogenomic Testing of Individuals with Cancer

Q

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

Quantitative Sensory Testing

Quantose Impaired Glucose Tolerance (IGT) Test

R

Radiation Oncology Services

Radiation Therapy forNon-Cancerous Conditions

RADICAVA (edaravone injection)

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 (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer

Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma

Radiopharmaceutical Agents and Other In Vivo Diagnostic Aids

Radiopharmaceutical Tumor Localization (SPECT), Single Area

Radium Ra 223 (Xofigo®) Injection

Ramucirumab (Cyramza®)

Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions

Redblood Cell Molecular Testing

Reduction Mammaplasty for Breast-Related Symptoms

Registered Nurses Practicing in Extended Roles

Repository Corticotropin Injection

Reproductive Techniques

Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

Retinal Prosthesis

Retinal Telescreening for Diabetic Retinopathy

Reverse Shoulder Arthroplasty

Risk-Reducing Mastectomy

Robotic Assisted Surgery - Reimbursement Policy

S

Sacral Nerve Neuromodulation/Stimulation

Salivary Hormone Testing

Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

Scintimammography and Gamma Imaging of the Breast and Axilla

Semi-Implantable and Fully Implantable Middle Ear Hearing Aids

Sensory Integration Therapy and Auditory Integration Therapy

Serum Testing for Evidence of Mild Traumatic Brain Injury

Serum Tumor Markers for Malignancies

Signal-Averaged Electrocardiography

Siltuximab (Sylvant)

SIMPONI ARIA (golimumab injection for intravenous use)

Sinus Maxillofacial CT

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

Small Bowel/Liver and Multivisceral Transplant

SPECT/CT Fusion Imaging

Speech Generating Devices

Sphenopalatine Ganglion Block for Headache

Spinal Cord and Dorsal Root Ganglion Stimulation

Spinal Epidural Injections

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

Steroid-Eluting Sinus Stents and Implants

Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy

Subtalar Arthroereisis and Subtalar Joint Implant

Sufentanil Sublingual Tablet (Dsuvia)

Surgery for Groin Pain in Athletes

Surgical and Ablative Treatments for Chronic Headaches

Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

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 Treatments for Lymphedema and Lipedema

Surgical Ventricular Restoration

Sympathetic Therapy for the Treatment of Pain

T

T-Wave Alternans

Tagraxofusp-erzs (Elzonris)

Targeted Phototherapy and Psoralen with Ultraviolet A for Vitiligo

TECENTRIQ™ (atezolizumab)

TEMPORAL BONE, MASTOID, ORBITS CT

Temporomandibular Joint Dysfunction

Teprotumumab-trbw (TEPEZZA™)

Testing for Alpha-1 Antitrypsin Deficiency

Testing for Autism Spectrum Disorder and Developmental Delay

Testing for Diagnosis of Active or Latent Tuberculosis

Testing for Mosquito- or Tick-Related Infections

Testing for Targeted Therapy of Non-Small-Cell Lung Cancer

Testing of Homocysteine Metabolism-Related Conditions

Testosterone Replacement Therapies

Testosterone Testing

Therapeutic Drug Monitoring for 5-Fluorouracil

Therapeutic Radiopharmaceuticals in Oncology

Thermal Capsulorrhaphy as a Treatment of Joint Instability

Thoracic-Lumbo-Sacral Orthosis with Pneumatics

Three-Dimensional Printed Orthopedic Implants

Threshold Electrical Stimulation as a Treatment of Motor Disorders

Thyroid Disease Testing

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 to Treat Primary or Metastatic Liver Malignancies

Transcatheter Mitral Valve Repair

Transcatheter Pulmonary Valve Implantation

Transcoronary Ablation of Septal Hypertrophy (TASH)

Transcranial Doppler Ultrasound

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

Transplant Rejection Testing

Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease

Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

Treatment of Hyperhidrosis

Treatment of Tinnitus

Treatment of Varicose Veins/Venous Insufficiency

Tumor Treating Fields Therapy

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 for the Evaluation of Paranasal Sinuses

Ultraviolet Light Therapy in the Home Setting (UVB)

Unicompartmental and Bicompartmental Knee Arthroplasties

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

UPPER EXTREMITY MRI (Hand, Wrist, Arm, Elbow, Long bone, or Shoulder MRI)

Urinary Tumor Markers for Bladder Cancer

Urine Culture Testing for Bacteria

Use of Common Genetic Variants (single nucleotide polymorphisms) to Predict Risk of Non-Familial Breast Cancer

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

Uses of Monoclonal Antibodies

ustekinumab (Stelara™)

V

Vacuum-Assisted Breast Biopsy

Vacuum Therapy as a Treatment for Female Sexual Dysfunction

Vagus Nerve Blocking Therapy for Treatment of Obesity

Vagus Nerve Stimulation

Vasectomy Using a Polymeric Clip

Vectra DA Blood Test for Rheumatoid Arthritis

Vedolizumab (Entyvio™)

Venous and Arterial Thrombosis Risk Testing

Vertebral Axial Decompression

Vertebral Fracture Assessment with Densitometry

Vertical Expandable Prosthetic Titanium Rib

Vestibular Function Testing

Videofluoroscopic Evaluation of Velopharyngeal Dysfunction

Viltepso® (Viltolarsen)

Viscocanalostomy and Canaloplasty

Vitamin B12 and Methylmalonic Acid Testing

Vitamin D Testing

VYONDYS 53 (golodirsen)

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 Genome and Whole Exome Sequencing

Whole Gland Cryoablation of Prostate Cancer

Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon

Wireless Pressure Sensors in Endovascular Aneurysm Repair

Women's Preventive Services

Work Hardening Programs

X

Y

Z

Zika Virus Risk Assessment

Zolgensma® (Onasemnogene Abeparvovec-Xioi)

ZOMETA (zoledronic acid)