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Demonstration Project #01

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Ablative Techniques as a Treatment for Barrett’s Esophagus

Activity Therapy for Autism Spectrum Disorders

& Rett Syndrome


Adaptive Behavioral Treatment for Autism Spectrum Disorder

Advanced Lipoprotein Testing

Adoptive Immunotherapy & Cellular Therapy

Air Conduction Hearing Aids

Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

Allergy Immunotherapy (Subcutaneous)

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


Closure After Discectomy

Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence

Artificial Retinal Devices

Axial Lumbar Interbody


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


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

Assistant Surgeons

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

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

Back-Up Ventilators in the Home Setting

Balloon Dilation of Eustachian Tube

Balloon Sinus

Ostial Dilation

Bariatric Surgery & Other Treatments for Clinically Severe Obesity

Beta Interferons & Glatiramer Acetate for Treatment of Multiple Sclerosis

Biocompartmental Knee


Biofeedback & Neurofeedback

Bone-Anchored & Bone Conduction Hearing Aids

BCR-ABL Mutation Analysis

Bioimpedance Spectroscopy Devices for the Detection & Management of Lymphedema

Biomagnetic Therapy

Blepharoplasty, Blepharoptosis Repair, & Brow Lift


Mutation Analysis

Breast Ductal Examination & Fluid Cytology Analysis

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

Blepharoplasty, Blepharoptosis Repair, & Brow Lift

Bronchial Thermoplasty

Cardiac Contractility Modulation Therapy

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



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

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

Coblation® Therapies for Musculoskeletal Conditions

Cochlear Implants & Auditory Brainstem Implants

Cognitive Rehabilitation


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

Convection Enhanced Delivery of Therapeutic Agents to the Brain

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



Custom-made Knee Braces

Deep Brain, Cortical, & Cerebellar Stimulation

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

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

Doppler-Guided Transanal Hemorrhoidal Dearterialization

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

Drug-Eluting Devices for Maintaining Sinus Ostial Patency

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

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

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

Enteral Carbidopa & Levodopa Intestinal Gel Suspension

Enzyme Replacement Therapy for Gaucher Disease

Epidermal Growth Factor Receptor (EGFR) Testing


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

Extracorporeal Shock Wave Therapy

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

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

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

Functional Endoscopic Sinus Surgery (FESS)

Fundus Photography

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 Transplantation

Heart/Lung 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






Home Enteral Nutrition



Home Oxygen Therapy

Home Phototherapy Devices for Neonatal Hyperbili-rubinemia

Hospital Beds

& Accessories



Hyperthermia for Cancer Therapy

Idiopathic Environmental Illness (IEI)

Imaging Techniques for Screening and Identification of Cervical Cancer

Implantable Infusion Pumps

Implantable Left Atrial Hemodynamic Monitor

Implantable Middle Ear Hearing Aids

Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

Implantable Interstitial Glucose Sensors

Implanted Devices for Spinal Stenosis

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

Immune Cell Function Assay

Immune Globulin (Ig) Therapy


Infant Home Apnea Monitors



Inhaled Nitric Oxide

Injectable Prescription Drugs

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

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)

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

Intraocular Epiretinal Brachytherapy

Intraocular Telescope

Intrapulmonary Percussive Ventilation Devices for Airway


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

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


Ketogenic Diet for Treatment of Intractable Seizures

Kidney Transplantation

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

Laser Treatment of Onychomycosis

Leadless Pacemaker

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

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


for Gynecomastia

Maternity Ultrasound in the Outpatient Setting



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

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


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

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