ACG-Anthem Demonstration Project

Abaloparatide (Tymlos™) Injection

Abatacept (Orencia®)

Ablative Techniques as a Treatment for Barrett’s Esophagus

Activity Therapy for Autism Spectrum Disorders

& Rett Syndrome

Acupuncture

Adaptive Behavioral Treatment for Autism Spectrum Disorder

Advanced Lipoprotein Testing

Adoptive Immunotherapy & Cellular Therapy

Ado-trastuzumab emtansine (Kadcyla®)

Agalsidase beta (Fabrazyme®)

Air Conduction Hearing Aids

Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

Alglucosidase alfa (Lumizyme®)

Allergy Immunotherapy (Subcutaneous)

Alpha-1 Allogeneic, Xenographic, Synthetic & Composite Products for Wound Healing & Soft Tissue Grafting

Annulus

Closure After Discectomy

Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence

Artificial Retinal Devices

Axial Lumbar Interbody

Fusion

Altered Auditory Feedback Devices for the Treatment of Stuttering

Ambulatory or Outpatient Surgery Center Procedures

Ambulance Services: Air

& Water

Ambulance Services: Ground; Emergent

Ambulance Services: Ground; Non-Emergent

Analysis of KRAS

Status

Analysis of PIK3CA Status

in Tumor Cells

Analysis of Proteomic Patterns

Ancillary Services for Pregnancy Complications

Anesthesia Services & Moderate (“Conscious”) Sedation

Anesthesia Services for Interventional Pain Management Procedures

Angiographic Evaluation & Endovascular Intervention for Dialysis Access Circuit Dysfunction

Ankle-Foot & Knee-Ankle-Foot Orthosesus

Anterior Segment Optical Coherence Tomography

Antihemophilic Factors & Clotting Factors

Antineoplaston Therapy

Asfotase Alfa (Strensiq™)

Assistant Surgeons

Auditory Brainstem Responses (ABRs) & Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

Asparagine Specific Enzymes (Asparaginase)

Autologous & Allogeneic Pancreatic Islet Cell Transplantation

Automated Evacuation of Meibomian Gland

Augmentative & Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)

Automated External Defibrillators for Home Use

Automated Nerve Conduction Testing

Autonomic Testing

Axicabtagene ciloleucel (Yescarta®)

Azacitidine (Vidaza®)

Back-Up Ventilators in the Home Setting

Balloon Dilation of Eustachian Tube

Balloon Sinus

Ostial Dilation

Bariatric Surgery & Other Treatments for Clinically Severe Obesity

Belatacept (Nulojix®)

Bendamustine Hydrochloride

Belimumab (Benlysta®)

Beta Interferons & Glatiramer Acetate for Treatment of Multiple Sclerosis

Biocompartmental Knee

Arthroplasty

Biofeedback & Neurofeedback

Bone-Anchored & Bone Conduction Hearing Aids

Bevacizumab (Avastin®) for Non-Ophthalmologic Indications

BCR-ABL Mutation Analysis

Bioimpedance Spectroscopy Devices for the Detection & Management of Lymphedema

Biomagnetic Therapy

Blepharoplasty, Blepharoptosis Repair, & Brow Lift

Bortezomib (Velcade®)

Botulinum

Toxin

BRAF

Mutation Analysis

Breast Ductal Examination & Fluid Cytology Analysis

Breast Procedures, including Reconstructive Surgery, Implants & Other Breast Procedures

Brentuximab Vedotin (Adcetris®)

Blepharoplasty, Blepharoptosis Repair, & Brow Lift

Cabazitaxel (Jevtana®)

Canakinumab (Ilaris®)

Cardiac Ion Channel Genetic Testing

Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

Cardiac Stress Testing with Electrocardiogram

Cardioverter Defibrillators

Carotid Sinus Baroreceptor Stimulation Devices

Carotid, Vertebral & Intracranial Artery Stent Placement with or without Angioplasty

Cataract

Removal

Surgery for Adults

Cell-Free Fetal DNA-Based Prenatal Testing

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

Central (Hip or Spine) Bone Density Measurement & Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry

Cervical & Thoracic Discography

Cervical Cancer Screening Using Cytology & Human Papillomavirus Testing

Cervical Traction Devices for Home Use

Cetuximab (Erbitux®)

Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)

Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) & Congenital Anomalies

Clinically Equivalent Cost Effective Services – Targeted Immune Modulators

Clostridial Collagenase Histolyticum Injection

Coblation® Therapies for Musculoskeletal Conditions

Cochlear Implants & Auditory Brainstem Implants

Convection Enhanced Delivery of Therapeutic Agents to the Brain

Cognitive Rehabilitation

Colonoscopy

Computed Tomography to Detect Coronary Artery Calcification

Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System

Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion Pump During the Post-Operative Period

Continuous Monitoring of Intraocular Pressure

Cooling Devices & Combined Cooling/Heating Devices

Corneal Collagen Cross-Linking

Cosmetic & Reconstructive Services of the Head & Neck

Cosmetic & Reconstructive Services of the Trunk & Groin

Cosmetic & Reconstructive Services: Skin Related

Cranial Remodeling Bands & Helmets (Cranial Orthotics)

Cryoablation for Plantar Fasciitis & Plantar Fibroma

Cryopreservation of Oocytes or Ovarian Tissue

Cryosurgical Ablation of Solid Tumors Outside the Liver

Custodial

Care

Custom-made Knee Braces

Deep Brain, Cortical, & Cerebellar Stimulation

Denosumab (Prolia®,

Xgeva®)

Destruction of Pre-Malignant Skin Lesions

Detection & Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

Diagnostic Fiberoptic Flexible Laryngoscopy

Diagnostic Nasal Endoscopys

Diaphragmatic/Phrenic Nerve Stimulation & Diaphragm Pacing Systems

Dihydroergotamine Mesylate Injection for the Treatment of Migraine or Cluster Headaches in Adults

DNA-Based Testing for Adolescent Idiopathic Scoliosis

Docetaxel (Docefrez™, Taxotere®)

Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

Doppler-Guided Transanal Hemorrhoidal Dearterialization

Doxorubicin Hydrochloride Liposome Injection

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

Drug Dosage, Frequency, & Route of Administration

Drug-Eluting Devices for Maintaining Sinus Ostial Patency

Drug Testing or Screening in the Context of Substance Use Disorder & Chronic Pain

Dupilumab (Dupixent®)

Durable Medical Equipment

Dynamic Low-Load Prolonged-Duration Stretch Devices

Dynamic Spinal Visualization (Including Digital Motion X-ray & Cineradiography/

Videofluoroscopy)Electrical Nerve Stimulation, Transcutaneous, Percutaneous

Electrical Nerve Stimulation, Transcutaneous, Percutaneous

Electrical Stimulation as a Treatment for Pain & Related Conditions: Surface & Percutaneous Devices

Electric Breast Pumps

Electric Tumor Treatment Field (TTF)

Electroenceph-alography & Video Electroencepha-lographic Monitoring

Electromyography & Nerve Conduction Studies

Electrothermal Shrinkage of Joint Capsules, Ligaments, & Tendons

Elosulfase alfa (Vimizim®)

Elotuzumab (Empliciti™)

Endobronchial Valve Devices

Endothelial Keratoplasty

Endometrial Ablation

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection & Aortic Transection

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Enfuvirtide (Fuzeon®)

Enteral Carbidopa & Levodopa Intestinal Gel Suspension

Enzyme Replacement Therapy for Gaucher Disease

Epidermal Growth Factor Receptor (EGFR) Testing

Epiduroscopy

Eribulin mesylate (Halaven®)

Esophageal pH Monitoring

External Ambulatory Event Monitors to Detect Cardiac Arrhythmias

External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings

Extracorporeal Carbon Dioxide Removal

Epidermal Growth Factor Receptor (EGFR) Testing

Extraosseous Subtalar Joint Implantation & Subtalar Arthroereisis

Facet Joint Allograft Implants for Facet Disease

Fecal Analysis in the Diagnosis of Intestinal Disorders

Fetal Surgery for Prenatally Diagnosed Malformations

FDA-Approved Biosimilar Products

Fibrillation or Atrial Flutter (Radiofrequency

& Cryoablation)

Focused Microwave Thermotherapy

for Breast Cancer

Fosaprepitant (Emend®)

Fractional Exhaled Nitric Oxide & Exhaled Breath Condensate Measurements for Respiratory Disorders

Fulvestrant (FASLODEX®)

Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

Functional Endoscopic Sinus Surgery (FESS)

Fundus Photography

Galsulfase (Naglazyme®)

Gastric Electrical Stimulation

Gene-Based Tests for Screening, Detection & Management of Prostate Cancer

Gene Expression Profile Tests for Multiple Myeloma

Gene Expression Profiling for Cancers of Unknown Primary Site

Gene Expression Profiling for Colorectal Cancer

Gene Expression Profiling for Managing Breast Cancer Treatment

Gene Expression Profiling of Melanomas

Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer’s Disease

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Genetic Testing for Cancer Susceptibility

Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts & Leukoencephalopathy Syndrome

Genetic Testing for Colorectal Cancer Susceptibility

Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy)

Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)

Genetic Testing for Endocrine Gland Cancer Susceptibility

Genetic Testing of an Individual’s Genome for Inherited Diseases

Genetic Testing for Inherited Peripheral Neuropathies

Genetic Testing for TP53 Mutations

Genetic Testing for Hereditary Pancreatitis

Genetic Testing for Macular Degeneration

Genetic Testing for PTEN Hamartoma Tumor Syndrome

Genetic Testing for Statin-Induced Myopathy

Genetic Testing for Frontotemporal Dementia (FTD)

Genetic Testing for CHARGE Syndrome

Genetic Testing to Confirm the Identity of Laboratory Specimens

Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Genicular Nerve Blocks & Ablation for Chronic Knee Pain

Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications

Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications

Growth Factors, Silver-based Products & Autologous Tissues for Wound Treatment & Soft Tissue Grafting

Growth Hormone

Heart/Lung Transplantation

Heart Transplantation

Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias

Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

Hematopoietic Stem Cell Transplantation for Hodgkin Disease & non-Hodgkin Lymphoma

Hematopoietic Stem Cell Transplantation for Genetic Diseases & Aplastic Anemias

Hematopoietic Stem Cell Transplantation for Germ Cell Tumors

Hematopoietic Stem Cell Transplantation for Autoimmune Disease & Miscellaneous Solid Tumors

High Frequency Chest Compression Devices for Airway Clearance

High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

High-Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) & Squamous Cell Cancer of the Anus

Hippotherapy

Hip

Resurfacing

Holter

Monitors

Home Enteral Nutrition

Home

Health

Home Oxygen Therapy

Home Phototherapy Devices for Neonatal Hyperbili-rubinemia

Hospital Beds

& Accessories

Hyaluronan Injections

Holter

Monitors

Hyperthermia for Cancer Therapy

Idiopathic Environmental Illness (IEI)

Idurasufase (Elaprase®)

Imaging Techniques for Screening and Identification of Cervical Cancer

Implantable Infusion Pumps

Implantable Left Atrial Hemodynamic Monitor

Implantable Middle Ear Hearing Aids

Implanted (Epidural & Subcutaneous) Spinal Cord Stimulators (SCS)

Immune Cell Function Assay

Immune Globulin (Ig) Therapy

Immunizations

Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

Implantable and Extended-Release Buprenorphine-Containing Products

Implantable Interstitial Glucose Sensors

Implanted Devices for Spinal Stenosis

Infant Home Apnea Monitors

Infertility

Drugs

Inhaled Nitric Oxide

Injection Treatment for Morton’s Neuroma

Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer

Inpatient Interfacility Transfers

Intensive In-home Behavioral Health Services

Intensive Programs for Pediatric Feeding Disorders

Interferon gamma-1b (Actimmune®)

Internal Rib Fixation Systems

Interspinous Process Fixation Devices

Intervertebral Stabilization Devices

Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation

Intracardiac Ischemia Monitoring

Intracytoplasmic Sperm Injection (ICSI)

Intradiscal Annuloplasty Procedures [IDET], [PIRFT] & [IDB])

Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

Intraocular Epiretinal Brachytherapy

Intraocular Telescope

Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

Intrapulmonary Percussive Ventilation Devices for Airway

Clearance

Intravascular Brachytherapy (Coronary and Non-Coronary)

Intravascular Optical Coherence Tomography (OCT)

Intravenous versus Oral Drug Administration in the Outpatient & Home Setting

Intravitreal Corticosteroid Implants

Intravitreal Treatment for Retinal Vascular Conditions

Investigational Criteria

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

In-Vivo Analysis of Gastrointestinal Lesions

Iontophoresis for Medical Indications

Irreversible Electroporation

Ixabepilone (Ixempra®)

Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays

Keratoprosthesis

Ketogenic Diet for Treatment of Intractable Seizures

Kidney Transplantation

Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

Laronidase (Aldurazyme®)

Laser Treatment of Onychomycosis

Level of Care: Advanced Radiologic Imaging

Level of Care: Advanced Radiologic Imaging

Level of Care: Hospital-Based Ambulatory Surgical Procedures & Endoscopic Services

Level of Care: Outpatient Physical Therapy, Occupational Therapy, & Speech-Language Pathology Services

Level of Care: Specialty Pharmaceuticals

Levoleucovorin Products

Lifting Devices for Use in the Home

Liver Transplantation

Locally Ablative Techniques for Treating Primary & Metastatic Liver Malignancies

Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)

Lower Limb Prosthesis

Low-Frequency Ultrasound Therapy for Wound Management

Lumbar Discography

Lung & Lobar Transplantation

Lung Volume Reduction Surgery

Lysis of Epidural Adhesions

Magnetic Resonance Neurography

Magnetic Source Imaging & Magnetoenceph-alography

Magnetization-prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)

Mandibular/Maxillary (Orthognathic) Surgery

Manipulation Under Anesthesia

Mastectomy

for Gynecomastia

Maternity Ultrasound in the Outpatient Setting

Maze

Procedure

Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

Mechanical Embolectomy for Treatment of Acute Stroke

Mechanized Spinal Distraction Therapy

Medical & Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders & Rett Syndrome

Medical Necessity Criteria

Medical Policy Formation

Melanoma Vaccines

Mesenchymal Stem Cell Therapy for the Treatment of Joint & Ligament Disorders, Autoimmune, Inflammatory & Degenerative Diseases

Methylenetetra-hydrofolate Reductase Mutation Testing

Microprocessor Controlled Lower Limb Prosthesis

Microvolt

T-Wave Alternans

Minimally Invasive Ablative Procedures for Epilepsy

Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

Mohs Micrographic Surgery

Molecular Marker Evaluation of

Thyroid Nodules

Molecular Profiling & Proteogenomic Testing for the Evaluation of Malignant Tumors

MRI of the

Bone Marrow

MRI of the Breast

MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis

Multiparametric Magnetic Resonance Imaging Fusion Targeted Prostate Biopsy

Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus

Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)

Myoelectric Upper Extremity Prosthetic Devices

Myringotomy & Tympanostomy Tube Insertion

Naltrexone Implantable Pellets

Naltrexone (Vivitrol®) Injections for the Treatment of Alcohol and Opioid Dependence

Nasal Surgery for the Treatment of Obstructive Sleep Apnea & Snoring

Nasal Valve Suspension

Natalizumab (Tysabri®)

Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging

Near-Infrared Spectroscopy Brain Screening for Hematoma Detection

Neonatal Levels

of Care

Nerve Graft after Prostatectomy

Nesiritide (Natrecor®)

Neural Therapy

Neuromuscular Stimulation in the Treatment of Muscle Atrophy

Neutron Beam Radiotherapy

Non-implantable Insulin Infusion

& Blood Glucose Monitoring Devices

Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton

Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin

Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting

Non-Obstetrical Transvaginal Ultrasonography

Occipital Nerve & Supraorbital Nerve Stimulation

Occipital Nerve Block Therapy for the Treatment of Headache & Occipital Neuralgia

Occupational Therapy

Ocriplasmin (Jetrea®) Intravitreal Injection Treatment

Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)

Off-Label Drug

& Approved Orphan Drug Use

Olaratumab (Lartruvo™)

Omalizumab (Xolair®)

Oral, Pharyngeal & Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Orthopedic Footwear

Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management

Outpatient Cardiac Rehabilitation

Outpatient Cystourethroscopy

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

Paclitaxel, protein-bound (Abraxane®)

Pancreas Transplantation & Pancreas Kidney Transplantation

Palonosetron

(Aloxi)

Panitumumab (Vectibix®)

Panniculectomy & Abdominoplasty

Partial-Hand Myoelectric Prosthesis

Partial Left Ventriculectomy

Paraesophageal Hernia Repair

Parenteral Antibiotics for the Treatment of Lyme Disease

Pediatric Gait Trainers

Pegloticase (Krystexxa®)

Pemetrexed Disodium (Alimta®)

Penile Prosthesis Implantation

Percutaneous

& Endoscopic Spinal Surgery

Percutaneous Ultrasonic Ablation of Soft Tissue

Percutaneous Vertebroplasty, Kyphoplasty & Sacroplasty

Peripheral Bone Mineral Density Measurement

Peripheral Nerve Blocks for Treatment of Neuropathic Pain

Perirectal Spacers for Use During Prostate Radiotherapy

Pertuzumab (Perjeta®)

PET/MRI

PET Scanning Using Gamma Cameras

Pharmacotherapy

for Hereditary Angioedema

Photocoagulation of Macular Drusen

Physical Therapy

Physiologic Recording of Tremor using Accelerometer(s)

& Gyroscope(s)

Plerixafor Injection (Mozobil™)

Pneumatic Compression Devices for Lymphedema

Powered Robotic Lower Body Exoskeleton Devices

Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs

Positron Emission Tomography (PET) & PET/CT Fusion

Prefabricated & Prophylactic Knee Braces

Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea

Preimplantation Genetic Diagnosis Testing

Preoperative Testing for Low Risk Invasive Procedures & Surgeries

Presbyopia & Astigmatism-Correcting Intraocular Lenses

Pressure Reducing Support Surfaces - Groups 1, 2 & 3

Preventive Health Guidelines

Private Duty Nursing in the Home Setting

Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women

Prolotherapy for Joint & Ligamentous Conditions

Prostate Saturation Biopsy

Positional

MRI

Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension

Protein Biomarkers for the Screening, Detection & Management of Prostate Cancer

Proteinase

Inhibitor

Therapy

Prothrombin G20210A (Factor II) Mutation Testing

Prothrombin Time Self-Monitoring Devices

Pulmonary Rehabilitation

Quantitative Muscle Testing Devices

Quantitative Sensory Testing

Radioimmunotherapy & Somatostatin Receptor Targeted Radiotherapy

Radiofrequency Ablation of the Renal Sympathetic Nerves

Radiofrequency Ablation to Treat Tumors Outside the Liver

Radiofrequency & Pulsed Radiofrequency Treatment of Trigger Point Pain Suprachoroidal Injection of a Pharmacologic Agent

Radiofrequency Neurolysis & Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

Radiostereometric Analysis (RSA)

Radium Ra 223 Dichloride (Xofigo®)

Recombinant Erythropoietin Products

Reduction Mammaplasty

Refractive

Surgery

Repository Corticotropin Injection (H.P. Acthar® Gel)

Respiratory Viral Panel Testing in the Outpatient Setting

Resting Electrocardiogram Screening in Adults

Retinal Telescreening Systems

Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline

Rhinophoto-therapy

Rilonacept (Arcalyst®)

Rituximab (Rituxan®) for Non-Oncologic Indications

Romidepsin (Istodax®)

Romiplostim (Nplate®)

Rupture of Membranes Testing in Pregnancy

Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury

Sacral Nerve Stimulation & Percutaneous Tibial Nerve Stimulation for Urinary & Fecal Incontinence; Urinary Retention

Sacroiliac

Joint Fusion

Sarilumab

(Kevzara®)

Screening & Assessment for Autism Spectrum Disorders and Rett Syndrome

Screening for Vitamin D Deficiency in Average Risk Individuals

Scrotal Ultrasound

Seat Lift

Mechanisms

Sebelipase alfa (KANUMA™)

Selected Blood, Serum & Cellular Allergy & Toxicity Tests

Selected Sleep Testing Services

Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver

Self-Expanding Absorptive Sinus Ostial Dilation

Self-Operated Spinal Unloading Devices

SensiGene® Fetal RhD Genotyping Test

Sensory Stimulation for Brain-Injured Patients in Coma or Vegetative State

Septoplasty

Serological Antibody Testing For Helicobacter Pylori

Serum Biomarker Tests for Multiple Sclerosis

Serum Markers for Liver Fibrosis in the Evaluation & Monitoring of Chronic Liver Disease

Sex Reassignment Surgery

Single Photon Emission Computed Tomography Scans for Noncardio-vascular Indications

Siltuximab (Sylvant®)

Sipuleucel-T (Provenge®)

Skilled Nursing & Skilled Rehabilitation Services (Outpatient)

Skin Nerve Fiber Density Testing

Small Bowel, Small Bowel/Liver, & Multivisceral Transplantation

SPECT/CT Fusion

Imaging

Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy

Speech-Language Pathology Services

Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), & Lumbar

Strapping

Standing

Frames

Static Progressive Stretch (SPS) & Patient-Actuated Serial Stretch (PASS) Devices

Stem Cell Therapy for Peripheral Vascular Disease

Stereotactic Radiofrequency Pallidotomy

Surgical & Ablative Treatments for Chronic Headaches

Surgical & Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) & Other Genitourinary Conditions

Surgical Strabismus Correction

Surgical Treatment for Dupuytren's Contracture

Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders

Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression

& Recurrence

Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy & Ultrasonography)

Temporoman-dibular

Disorders

Temsirolimus (Torisel®)

Testing for Oral & Esophageal Cancer

Testosterone Injectable

Therapeutic Apheresiss

Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes

Three-Dimensional (3-D) Rendering of Imaging Studies

Tisagenlecleucel (Kymriah®)

Tocilizumab (Actemra®)

Tonsillectomy for Children with or without Adenoidectomy

Topographic Genotyping

Total Ankle Replacement

Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions

Transanal Radiofrequency Treatment of Fecal Incontinence

Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins

Transcatheter Arterial Chemoembol-ization (TACE)

& Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS)

& Spinal Cord

Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

Transcatheter Arterial Chemoemboli-zation (TACE)

& Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors

Transcatheter

Heart Valve Procedures

Transcatheter Uterine Artery Embolization

Transcranial Magnetic Stimulation

Transendoscopic Therapy for Gastroesophageal Reflux Disease & Dysphagia

Transmyocardial/Perventricular Device Closure of a Ventricular Septal Defects

Transmyocardial Revascularization

Transrectal Ultrasonography

Transtympanic Micropressure for the Treatment of Ménière’s Disease

Treatment of Hyperhidrosis

Treatment of Keloids & Scar Revision

Treatment of Varicose Veins (Lower Extremities)

Treatments for Urinary Incontinence

Trigger Point Injections

Tropism Testing for HIV Management

Tumor Necrosis Factor Antagonists

Umbilical Cord Blood Progenitor Cell Collection, Storage & Transplantation

Ultrafiltration in Decompensated Heart Failure

Ultrasound Bone Growth

Stimulations

Ultrasound for the Evaluation of Paranasal Sinuses

Unicondylar Interpositional Spacer

Upper Extremity Myoelectric Orthoses

Upper Gastrointestinal Endoscopy in Adults

Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care

Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®) & Direct Thrombin Inhibitors in the Outpatient Setting

Ustekinumab (Stelara®)

Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques

Vacuum Assisted Wound Therapy in the Outpatient Setting

Vagus Nerve Stimulation

Vedolizumab (Entyvio®)

Vena Cava

Filters

Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

Vertebral Body Stapling for the Treatment of Scoliosis in Children & Adolescents

Vertical Expandable Prosthetic Titanium Rib

Viscocanalostomy & Canaloplasty

Visual, Somatosensory & Motor Evoked Potentials

Voretigene neparvovec-rzyl (Luxturna™)

Wearable Cardioverter Defibrillators

Wheeled Mobility Devices: Manual Wheelchairs-Standard, Heavy Duty and Lightweight

Wheeled Mobility Devices: Manual Wheelchair-Ultra Lightweight

Wheeled Mobility Devices: Wheelchair Accessories

Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems

& Power Operated Vehicles (POVs)

White Blood Cell Growth Factors

Whole Body Computed Tomography Scanning

Wilderness Programs

Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders

Wound Care

in the Home Setting

Zika Virus

Testing

Ziv-aflibercept (Zaltrap®)

Zoledronic Acid

Copyright 2006-2019 Automated Clinical Guidelines, LLC. All rights reserved.