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Demonstration Project #01

Nasal Surgery for the Treatment of Obstructive Sleep Apnea & Snoring

Nasal Valve Suspension

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

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

Pancreas Transplantation & Pancreas Kidney Transplantation

Panniculectomy & Abdominoplasty

Partial-Hand Myoelectric Prosthesis

Partial Left Ventriculectomy

Parenteral Antibiotics for the Treatment of Lyme Disease

Pediatric Gait Trainers

Penile Prosthesis Implantation

Percutaneous

& Endoscopic Spinal Surgery

Percutaneous Ultrasonic Ablation of Soft Tissue

Peripheral Bone Mineral Density Measurement

Peripheral Nerve Blocks for Treatment of Neuropathic Pain

Perirectal Spacers for Use During Prostate Radiotherapy

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)

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 Oral Appliances for the Treatment of Obstructive Sleep Apnea

Preimplantation Genetic Diagnosis Testing

Presbyopia & Astigmatism-Correcting Intraocular Lenses

Pressure Reducing Support Surfaces - Groups 1, 2 & 3

Preventive Health Guidelines

Private Duty Nursing in the Home Setting

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

Radiostereometric Analysis (RSA)

Reduction Mammaplasty

Refractive

Surgery

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

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

Screening & Assessment for Autism Spectrum Disorders and Rett Syndrome

Screening for Vitamin D Deficiency in Average Risk Individuals

Scrotal Ultrasound

Seat Lift

Mechanisms

Selected Blood, Serum & Cellular Allergy & Toxicity Tests

Selected Sleep Testing Services

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

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

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

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

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

Tonsillectomy for Children with or without Adenoidectomy

Topographic Genotyping

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

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

Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques

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

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

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

Wound Care

in the Home Setting