Demonstration Project #01
Epidural Injection Procedures & Diagnostic Selective Nerve Root Blocks
Paravertebral Facet Injection - Nerve Block - Neurolysis
Regional Sympathetic Nerve Block
Sacroiliac Joint Injection
Spinal Cord Stimulators
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
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
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
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
Arthroplasty
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
BRAF
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
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
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
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
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
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
Epiduroscopy
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
Hippotherapy
Hip
Resurfacing
Holter
Monitors
Home Enteral Nutrition
Home
Health
Home Oxygen Therapy
Home Phototherapy Devices for Neonatal Hyperbili-rubinemia
Hospital Beds
& Accessories
Holter
Monitors
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
Immunizations
Infant Home Apnea Monitors
Infertility
Drugs
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
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
Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
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
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
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
™