Medical Policy Demonstration Project #04
Abortion
Acupuncture
Adoptive Immunotherapy
Airway Clearance Devices in the Ambulatory Setting
Allergy Testing & Non-
Pharmacologic Treatment
Ambulatory Assistance
Devices
Anesthesia & Facility Services for Dental Treatment
Atherosclerotic Cardiovascular Disease Risk Assessment: Emerging Laboratory Evaluations
Athletic Pubalgia Surgery
Attention-Deficit /Hyperactivity Disorder (ADHD): Assessment & Treatment
Autism Spectrum Disorders/ Pervasive Developmental Disorders: Assessment & Treatment
Autologous Cell Therapy for Cardiac & Peripheral Arterial Disease
Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP])
Autonomic Nerve Function Testing
Axial/Spinal Decompression Therapy /Mechanical Traction (Provided in a Clinic Setting)
Balloon Sinus Ostial Dilation for Chronic Sinusitis
Bariatric
Surgery
Bathroom & Toilet Equipment & Supplies
Benign Prostatic Hyperplasia (BPH) Treatments
Biofeedback
Biventricular Pacing/Cardiac Resynchronization Therapy (CRT)
Blepharoplasty, Reconstructive Eyelid Surgery,
& Brow Lift
Bone, Cartilage,
& Ligament
Graft Substitutes
Bone Growth Stimulators: Electrical (Invasive, Noninvasive), Ultrasound
Bone Mineral Density Measurement
Breast Implant Removal
Breast
Pumps
Breast Reconstruction Following Mastectomy or Lumpectomy
Bronchial Thermoplasty
Capsule Endoscopy
Cardiac Electrophysiological (EP) Studies
Cardiac Rehabilitation (Phase II Outpatient)
Carotid Intima-Media Thickness Measurement
Cervical Cancer Screening Visualization Technologies
Cervical
Fusion
Chiropractic
Care
Clinical Trials
Cochlear & Auditory Brainstem Implants
Cognitive Rehabilitation
Colorectal Cancer Screening & Surveillance
Complementary & Alternative Medicine
Comparative Genomic Hybridization (CGH)/Chromosomal Microarray Analysis (CMA) for Selected Hereditary Conditions
Complex Lymphedema Therapy (Complete Decongestive Therapy)
Computerized Dynamic Posturography (CDP)
Computerized Electrocardiograph (ECG) Analysis
Continuous Passive Motion (CPM) Devices
Corneal Remodeling
Cranial Orthotic Devices for Positional or Deformational Plagiocephaly
Cryoablation
of Breast
Lesions
Cryounits /Cooling Devices
Deep Brain, Motor Cortex
& Responsive Cortical Stimulation
Dermabrasion
& Chemical
Peels
Diabetes Self-Management Education
Diabetic Supplies
Diagnostic Microbe Testing for Sexually Transmitted Diseases (STD)
Diaphragmatic/Phrenic Nerve Stimulation
Discography
Distraction Osteogenesis (DO) for Craniofacial Deformities
Donor Lymphocyte Infusion and Hematopoietic Progenitor Cell (HPC) Boost
Drug-Eluting Devices for
Use Following Endoscopic Sinus Surgery
Drug
Testing
Electrical Stimulation Therapy & Home Devices
Electric Stimulation for Pain, Swelling
& Function in a Clinic Setting
Electrodiagnostic Testing EMG NCV
Electroenceph-alography
Emergency Room
Services
Emerging Surgical Procedures for Glaucoma
Endometrial Ablation
Endoscopic
Anti-Reflux Procedures
Epidural Adhesiolysis
Epidural Steroid Injections
Exhaled Nitric Oxide & Exhaled Breath Condensate in the Management of Respiratory
Disorders
External Counter-pulsation
External
Insulin
Pumps
Extracorporeal Photopheresis
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions & Soft Tissue Wounds
Facet Joint Injections / Medial Branch Blocks
Fecal Bacteriotherapy
Fetal
Surgery
Foot Care Services
Gait Analysis
Gastric Pacing/Gastric Electrical Stimulation (GES)
Genetic Expression Profiles for Detection of Heart Transplantation Rejection
(e.g., AlloMap)
Genetic Testing Collateral Document
Genetic Testing Collateral-Not Covered Single CPT & HCPCS Code Tests
Genetic Testing for Hereditary & Multifactorial Conditions
Genetic Testing for Hereditary Cancer Susceptibility Syndromes
Genetic Testing for Hereditary Cardiomyopathies & Arrhythmias
Genetic Testing for Reproductive Carrier Screening & Prenatal Diagnosis
Hallux Valgus Surgery (Bunionectomy)
Hammer Toe Surgery
Headache & Occipital Neuralgia Treatment
Hearing
Aids
Heart, Lung,
& Heart-Lung Transplantation
Helicobacter Pylori Serology Testing
High Intensity Focused Ultrasound (HIFU)
Hip Replacement /Arthroplasty
Hip Surgery - Arthroscopic
& Open Procedures
Home Blood Glucose
Monitors
Home Traction Devices - Cervical & Lumbar
Hospice
Care
Hospital Beds
& Accessories
Hospitalization for the Initiation of a Ketogenic Diet
Hyperbaric Oxygen Therapy, Systemic & Topical
Hyperhidrosis Treatments
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Implantable Cardioverter Defibrillator (ICD)
Implantable Infusion Pump for Non-Musculoskeletal Conditions
Implantable Intrathecal Drug Delivery Systems
Infertility Services
Inhaled Nitric Oxide (INO)
Injectable Bulking Agents for Urinary Conditions & Fecal Incontinence
Injectable
Fillers
Inpatient Acute Rehabilitation
Inpatient Admission for Radiation Therapy
Intensive Behavioral Interventions
Interspinous Process Spacer Devices
Intervertebral Disc (IVD) Prostheses
Intestinal & Multivisceral Transplantation
Intraocular
Lens Implant
Intraoperative Monitoring
Kidney Transplantation, Pancreas-Kidney Transplantation, & Pancreas Transplantation Alone
Knee
Braces
Knee Replacement/Arthroplasty
Knee Surgery: Arthroscopic & Open Procedures
Laser
Interstitial Thermal
Therapy
Liver Transplantation
Lower Limb Orthoses & Shoes
Low-Level Laser & High-Power Laser Therapy
Lumbar Fusion for Spinal Instability & Degenerative Disc Conditions, including Sacroiliac Fusion
Lyme Disease Treatment - Antibiotic Treatment
Male Sexual Dysfunction Treatment: Non-pharmacologic
Malignant Melanoma Surveillance Technologies
Mammary Ductoscopy, Aspiration & Lavage
Mammography (Screening)
Manipulation Under Anesthesia (MUA)
Manual Muscle Testing & Range of Motion Testing
Mechanical Devices for the Treatment of Back Pain
Metatarso-phalangeal
Joint Replacement
Microwave Thermotherapy for Breast Cancer
Midwife, Home Birth & Non-Clinical Maternal Services
Minimally Invasive Intradiscal /Annular Procedures & Trigger Point Injections
Miscellaneous Musculoskeletal Procedures
Myoelectric Devices: Upper Limb
Negative Pressure Wound Therapy/Vacuum-Assisted Closure (VAC) for Nonhealing Wounds
Neuropsycho-logical Testing
Non-Participating Laboratory Services
Nutritional Support
Obstructive Sleep Apnea Treatment Services
Occupational Therapy
Omnibus
Codes
Oral Cancer Screening Systems
Orthognathic Surgery
Otoplasty & External Ear Reconstruction
Outpatient
Acute Rehabilitation
Oxygen for Home Use
Pancreatic Islet Cell Transplantation
Panniculectomy & Abdominoplasty
Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations &
Re-evaluations
Pediatric Intensive
Feeding Programs
Pelvic Denervation Procedures
Percutaneous Revascularization of the Lower Extremities in Adults
Percutaneous Vertebroplasty, Kyphoplasty & Sacroplasty
Peripheral Nerve Destruction for Pain Conditions
Pharmacogenetic Testing
Phototherapy, Photochemotherapy, & Excimer Laser Therapy for Dermatologic Conditions
Physical Performance Measurement
Physical Therapy
Plantar Fasciitis Treatments
Plasma Brain Natriuretic Peptide in the Outpatient Setting
Plasmapheresis
Pneumatic Compression Devices & Compression Garments
Preoperative Inpatient
Admissions
Pressure Reducing Surfaces
Preventive
Care
Services
Prolotherapy
Prophylactic Mastectomy
Prophylactic Oophorectomy or Salpingo-oophorectomy With or Without Hysterectomy
Prostate-Specific Antigen (PSA) Screening for Prostate Cancer
Prosthetic Devices: External Facial, Internal Ocular
Prosthetic Devices: Lower Limb (Including Vacuum-Assisted Socket System & Microprocessor /Computer-Controlled Lower Limb Prostheses)
Prothrombin Time Home Testing Systems
Pulmonary Rehabilitation
Pulsed Electromagnetic Therapy
Radiofrequency Ablation for Breast Cancer
Radiofrequency Joint Ablations /Denervation
Recurrent Pregnancy Loss: Diagnosis & Treatment
Reduction Mammoplasty
Redundant Skin
Surgery
Regional Sympathetic Blocks
Rhinoplasty, Vestibular Stenosis Repair & Septoplasty
Rosacea Procedures
Sacral Nerve & Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence & Constipation
Sacroiliac Joint Injections
Scar
Revision
Screening Mammography
Seat Lift Mechanism, Patient Lifts & Standing Devices
Sensory & Auditory Integration Therapy - Facilitated Communication
Serological Testing for Inflammatory Bowel Disease
Shoulder Arthroplasty / Replacement / Resurfacing / Revision / Arthrodesis
Shoulder Surgery - Arthroscopic & Open Procedures
Sleep Testing Services
Speech Generating Devices
Speech
Therapy
Spinal Cord & Implanted Peripheral Nerve Stimulation
Spinal
Orthoses
Spinal Ultrasound
Staff-Assisted Home
Hemodialysis
Stem Cell Transplantation: Blood Cancers
Stem Cell Transplantation for Adult Solid Tumors
Stem Cell Transplantation for Aplastic Anemia & Fanconi Anemia
Stem Cell Transplantation for Autoimmune Diseases /Miscellaneous Conditions
Stem Cell Transplantation for Breast Cancer
Stem Cell Transplantation for Central Nervous System Tumors
Stem Cell Transplantation for Inherited Metabolic Disorders
Stem Cell Transplantation Myelofibrosis & Polycythemia Vera
Stem Cell Transplantation for Neuroblastoma
Stem Cell Transplantation for Primary Immunodeficiency Disorders
Stem Cell Transplantation for Sickle Cell Disease & Thalassemia Major
Stem Cell Transplantation for Solid Tumors in Children
Strapping & Taping
Stretch Devices for Joint Stiffness & Contractures
Stuttering Treatment Devices
Subtalar Arthroereisis
Suit
Therapy
Surgical Treatment for Chest Wall Deformities
Surgical Treatment of Gynecomastia
Surgical Treatment of Lymphedema
& Lipedema
Temporo-mandibular Joint (TMJ) Disorder Surgery
Tests for the Evaluation of Preterm Labor
& Premature Rupture of Membranes
Thermal Shrinkage
Thoracic Electrical Bioimpedance for the Measurement of Cardiac Output
Tilt
Table
Testing
Tissue Engineered Skin Substitutes
Total Ankle Arthroplasty /Replacement
Total Artificial Heart
Transcatheter Ablation for the Treatment of Supraventricular Tachycardia in Adults
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins for the Treatment of Atrial Fibrillation
Transcatheter Closure of Cardiovascular Defects
Transcatheter Heart Valve Procedures
Transcranial Magnetic Stimulation
Transplantation Donor Charges
Transthoracic Echocardiography in Adults
Transthoracic Echocardiography in Children
Transvaginal Ultrasound,
Non-Obstetrical
Treatment of Cutaneous and/or Deep Tissue Hemangioma, Port Wine Stain & Other Vascular Lesions
Treatment of Gender Dysphoria
Tumor In Vitro Chemosensitivity & Chemoresistance Assays
Tumor Profiling, Gene Expression Assays & Molecular Diagnostic Testing for Hematology / Oncology Indications
Ultrasound in Pregnancy (including 3D & 4D Ultrasound)
Umbilical Cord Blood Banking
Vagus Nerve Stimulation (VNS)
Varicose Vein Treatments
Ventilator Weaning
Ventricular Assist Devices (VADs)
& Percutaneous Cardiac Support Systems
Vision Therapy/Orthoptics
Visual Perceptual Training
Vitamin D
Testing
Wearable Cardioverter Defibrillator & Automatic External Defibrillator
Wheelchairs/Power Operated Vehicles
Whole Body Dual X-Ray Absorptiometry (DXA)
Whole Exome & Whole Genome Sequencing
Vision Therapy/Orthoptics
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