ACG-Cigna Medical Policy Demonstration Project

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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