ACG-South Carolina Blue Demonstration Project

Abatacept (Orencia®)

Abdominoplasty, Panniculectomy

& Lipectomy

Ablation of Peripheral Nerves to Treat Pain

Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

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

Acoustic Cardiography

Actigraphy

Acupuncture & Dry Needling

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

Adjustable Cranial Orthoses for Positional Plagiocephaly & Craniosynostoses

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

Adoptive Immunotherapy

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 & Myeloproliferative Neoplasms

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

Allogeneic Pancreas Transplant

Ambulance & Medical

Transport

Services

Ambulatory Event Monitors & Mobile Cardiac Outpatient Telemetry

Amniotic Membrane & Amniotic Fluid

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

ANA/ENA Testing

Anesthesia Services

Angelchik™ Anti-Reflux Prosthesis

Antineoplaston Therapy & Sodium Phenylbutyrate

Aqueous

Shunts & Devices for Glaucoma

Arthroscopic Debridement & Lavage as Treatment for Osteoarthritis of the Knee

Artificial

Pancreas

Device

Systems

Auditory Brainstem Implant

Autografts & 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

& Gliomas

Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure

Automated Percutaneous and Percutaneous Endoscopic Discectomy

Automated Point-of-Care Nerve Conduction Tests

Autonomic Nervous System Testing

Avelumab (Bavencio®)

Axial Lumbosacral Interbody

Fusion

Back

School

Balloon Dilatation

of Prostate

Balloon Dilation of the Eustachian Tube

Balloon Sinuplasty for Treatment of Chronic

Sinusitis

Bariatric

Surgery

Baroreflex Stimulation Devices

BCR-ABL1 Testing in Chronic Myelogenous Leukemia & Acute Lymphoblastic Leukemia

Behavioral Health Guidelines

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

Biochemical Markers of Alzheimer Disease & 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 & Management of Lymphedema

Biomarker Testing for Multiple Sclerosis & Related Neurologic Diseases

BioZorb®

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

Blepharoplasty (Upper & Lower)

Blinatumomab (Blincyto)

Bone

Mineral

Density

Studies

Bone Morphogenetic Protein

Bone

Turnover Markers

Testing

Botulinum Toxin

Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

BRAF Genetic Testing in Patients with Melanoma

Brain

Natriuretic Peptide

(BNP)

BRCA

Breast Duct Endoscopy

Breast Pumps

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

Canalith Repositioning as a Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

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 & Fetal Xenograft)

Cellular Immunotherapy for Prostate Cancer

Cemiplimab-rwlc (Libtayo®)

Cervical Cancer Screening Technologies with Pap & HPV

Cervical

Spine Procedures

Cervical

Spine

Surgery

Cervicography

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

Chelation Therapy for Off-Label Uses

Chemical

Peels

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

Chiropractic Services

Chromoen-doscopy as an Adjunct to Colonoscopy

Chromosomal Microarray

Chronic Intermittent Intravenous Insulin Therapy (CIIIT)

Chronic Pulmonary Thromboendart-erectomy

Cimzia® (certolizumab pegol)

Clinical Trials for Cancer

& Life-Threatening Conditions

Cochlear Implant

Cognitive Rehabilitation

Colorectal Cancer Screening

Composite Tissue Allotransplan- tation of the Hand & Face

Computed Tomography to Detect Coronary Artery Calcification

Computed Tomography (CT) Perfusion Imaging of the Brain

Computer-Assisted Navigation for Orthopedic Procedure

Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease

Concurrent Care

Confocal Laser Endomicro-scopy

Conjunctival Incision with Posterior Juxtascleral Placement of Anecortave Acetate Depot Suspension

Continent Ileostomy & Urostomy

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

Continuous Passive Motion (CPM) in the Home Setting

Contraceptive Management

Contrast Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation

Cooling Devices Used in the Outpatient Setting

Corneal Collagen Cross-linking

Corneal Topography/Computer-Assisted Corneal Topography/Photokeratos-copy

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

Cosmetic/Reconstructive Services

Cranial Electrotherapy Stimulation (CES) & Auricular Electrostimulation

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate Tumors or Dermatologic Tumors

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

CT Scanning of the Chest (Thorax) & Chest (Non-Coronary) Computed Tomography Angiography (CTA)

Cutaneous Electrogastro-graphy (EGG)

Daily Hemodialysis & 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

Diagnosis & Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology)

Diagnosis & Medical Management of Obstructive Sleep Apnea Syndrome

Diagnosis & Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis

Diagnosis & 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)

Drug

Coverage

Dry Needling & Trigger Point Injections for Myofascial Pain

Durable Medical Equipment (DME)

Dynamic Cardiomyoplasty

Dynamic Posturography

Dynamic

Spinal Visualization

Electrical Bone Growth Stimulation of the Appendicular Skeleton

Electrical Impedance Scanning of the Breast

Electrical Stimulation for the Treatment of Arthritis

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

Electrocard-iographic Body Surface Mapping

Electrocorti-cography

Electroencep-halograms (EEG)

Electromagnetic Navigation Bronchoscopy

Electronic Brachytherapy for Nonmelanoma Skin Cancer

Electrophrenic Pacemaker

Electrostim-ulation & Electromag-netic Therapy for the Treatment of Chronic Wounds

Emapalumab-lzsg (Gamifant)

End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema

Endobronchial Brachytherapy

Endobronchial Ultrasound for Diagnosis & Staging of Lung Cancer

Endometrial Ablation

Endoscopic Injection Sclerotherapy for Esophageal Varices

Endoscopic Laser for Gastrointes-tinal Bleeding

Endoscopic Laser for Tracheobron-chial Obstructions

Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus

Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis & 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 Counterpul-sation (EECP)

Enteral Carbidopa & Levodopa Intestinal Gel Suspension

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

Epithelial Cell Cytology in Breast Cancer Risk Assessment & High-Risk Patient Management (Ductal Lavage

& Suction Collection Systems)

Erectile Dysfunction

Erythopoiesis Stimulating Agents & Darbepoetin Alfa (Aranesp)

Esophageal

pH Monitoring

Eteplirsen for Duchenne Muscular Dystrophy

Evaluation of Hearing Impairment

Extended-Release Injectable (Sublocade)

External Insulin Infusion Pump

Extracorpor-eal Immunoad-sorption Using Protein A Columns

Extracorpor-eal Membrane Oxygenation for Adult Conditions

Extracor-poreal Photopheresis

Extracor-poreal Shock Wave Therapy in the Treatment of Peyronie's Disease

Extracorporeal Shock Wave Treatment for Plantar Faciitis

& Other Musculoskeletal Conditions

Extracranial Carotid Angioplasty/Stenting

Eye Movement Desensitization & Reprocessing (EMDR) Therapy

Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

Facet Arthroplasty

Familial Adenomatous Polyposis & MUYTH-Associated Polyposis Testing

FDG Using Camera-Based Imaging (FDG-SPECT)

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

Fecal Microbiota Transplan-tation

Fetal Fibronectin Enzyme Immunoassay

Fetal Surgery for Prenatally Diagnosed Malformations

Flow Cytometry

Focal Treatments for Prostate Cancer

Folate Testing

Fractional Flow Reserve CT

Functional Magnetic Resonance Imaging of the Brain

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

Gait

Analysis

Gas Permeable Scleral Contact Lens

Gastric Electrical Stimulation

Gender Reassignment Surgery

Gene Expression Profiling & Protein Biomarkers for Prostate Cancer Management

Gene Expression Profiling for Uveal Melanoma

Gene Expression Testing for Breast Cancer Prognosis

Gene Expression‒Based Assays for Cancers of Unknown Primary

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 Expression Profiling & Genetic Testing for Cutaneous Malignant Melanoma

Genetic Testing for Acute Myeloid Leukemia

Genetic Testing for Adolescent Idiopathic Scoliosis

Genetic Testing for Alpha- & Beta-Thalassemia

Genetic Testing for Alzheimer’s Disease

Genetic Testing for CHARGE Syndrome

Genetic Testing for Cystic Fibrosis

Genetic Testing for Duchenne, Becker, Facioscapulohu-meral, & Limb-Girdle Muscular Dystrophies

Genetic Testing for Epilepsy

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 Hemochro-matosis

Genetic Testing for Hereditary Pancreatitis

Genetic Testing for Heterozygous Familial Hypercholester-olemia

Genetic Testing for Inherited Cardiomy-opathies & Channel-opathies

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 Macular Degeneration

Genetic Testing for Mental Health Conditions

Genetic Testing for Neurofibroma-tosis & Related Disorders

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 & Ablation for Chronic Knee Pain

Golimumab (Simponi) for subcutaneous use

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 & 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 & POEMS Syndrome

Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia

Hematopoietic Stem Cell Transplantation for Autoimmune Diseases

Hemoglobin A1c

Hepatitis C testing

Hereditary Angioedema Drug Therapy

High-Dose Rate Temporary Prostate Brachytherapy

Hip

Resurfacing

Hippotherapy

HIV Genotyping & Phenotyping

Home Cardiorespir-atory Monitoring

Home Health Services Policy

Home Phototherapy for Neonatal Jaundice

Home Prothrombin Time Monitoring

Home Spirometry

Home Uterine Activity Monitoring

Hospice Care

Hospital Medical Services (Inpatient & Observation) & Consultation

Human Antihemophilic Factor (AHF)

Human Growth Hormone

Human Papillomavirus (HPV) Vaccines

Hyperbaric Oxygen Therapy

Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal & Pelvic Malignancies

Hypnosis

Hypothermia to Prevent/Reduce Hair Loss During Chemotherapy

Identification of Microorganisms Using Nucleic Acid Probes

Ilizarov Bone-Lengthening Procedure

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

Immunopharm-acologic 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 & Spasticity

Implantation of Intrastromal Corneal Ring Segments

In Vitro Chemoresis-tance & Chemosen-sitivity Assays

Incapacitated Dependent Coverage

InflammaDry Test

Inflectra™ (infliximab-dyyb)

Infliximab

Influenza Vaccine

Infrared Coagulation for Hemorrhoids

Ingestible pH & Pressure Capsule

Inhaled Nitric Oxide

Injectable Bulking Agents for the Treatment of Urinary & Fecal Incontinence

Injectable Clostridial Collagenase for Fibroproliferative Disorders

Inpatient Intestinal Rehabilitation Therapy

Inpatient Rehabilitation

Insulin Potentiation Therapy

Intensity-Modulated Radiation Therapy (IMRT): Abdomen & Pelvis

Intensity-Modulated Radiotherapy of the Breast & Lung

Intensity-Modulated Radiotherapy of the Prostate

Intensity-Modulated Radiotherapy: Cancer of the Head & 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

Interleukin 2 as a Treatment for HIV Infection

Interspinous & Interlaminar Stabilization/Distraction Devices (Spacers)

Interspinous Fixation (Fusion) Devices

Interventions for Progressive Scoliosis

Intra-Articular Hyaluronan Injections for Osteoarthritis

Intracardiac Electrophysio-logic Studies

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 Neurophysiol-ogic Monitoring

Intraoperative Radiotherapy

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

Intravenous Anesthetics for the Management of Chronic Neuropathic Pain

Intravenous Antibiotic Therapy for Lyme Disease

Intravenous or Subcutaneous Histamine Therapy

Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions

Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions

Intravitreal Corticosteroid Implants

Iontophoresis  & Phonophoresis

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