Demonstration Project #09
Ablation Procedures for Peripheral Neuromas
Ablative Procedures of Peripheral Nerves to Treat Pain
Ablative Treatments for Occipital Neuralgia, Chronic Headaches, and Atypical Facial Pain
Actigraphy
Acute Inpatient Hospice
Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
Adoptive Immunotherapy
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension
Alcohol Injections for Treatment of Peripheral Neuromas
Allergy Testing
Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases & Acquired Anemias
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
ALK Tyrosine Kinase Inhibitors
Ambulance & Medical Transport Services
Amniotic Membrane & Amniotic Fluid
Ampyra® (Dalfampridine)
Antibody-Drug Conjugates
Antidepressants: Pharmacy Medical Necessity Criteria for Brands
Applied Behavior Analysis (ABA)
Artificial Intervertebral Disc: Cervical Spine
Artificial Intervertebral Disc: Lumbar Spine
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
Automated Percutaneous & Percutaneous Endoscopic Discectomy
Automated Point-of-Care Nerve Conduction Tests
Axial Lumbosacral Interbody Fusion
Balloon Dilation of the Eustachian Tube
Bariatric
Surgery
BCR-ABL
Kinase
Inhibitors
Behavioral Health: Residential/Sub-Acute Detoxification
Bioengineered Skin & Soft Tissue Substitutes
Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery
Bone Mineral Density Studies
BRAF & MEK Inhibitors
Bronchial Thermoplasty
Bronchial Valves
Bruton’s Kinase Inhibitors
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
Cardiac Rehabilitation in the Outpatient Setting
Cardiovascular Risk Panels
Cellular Immunotherapy for Prostate Cancer
Cervical Spine Surgeries: Discectomy, Laminectomy, & Fusion in Adults
CGRP Inhibitors for Migraine Prophylaxis
Chelation Therapy
Chiropractic
Services
Cialis® (tadalafil) for Benign Prostatic Hyperplasia
Closure Devices for Patent Foramen Ovale & Atrial Septal Defects
Cochlear
Implant
Cognitive (Neurologic) Rehabilitation in the Outpatient Setting
Colonoscopy
Composite Tissue Allotransplantation of the Hand & Face
Computerized Diagnostic Imaging for Complex Maxillofacial Procedures
Continuity of Coverage for Maintenance Medications
Cooling Devices Used in the Outpatient Setting
Continuous Passive Motion in the Home Setting
Corneal Collagen
Cross-Linking
Coronary Angiography for Known or Suspected Coronary Artery Disease
Cosmetic & Reconstructive Services
Coverage Criteria of Excluded Drugs for Essentials Formulary
Cranial Electrotherapy Stimulation & Auricular Electrostimulation
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
Cutaneous
T-Cell Lymphomas (CTCL): Systemic Therapies
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
Deep
Brain
Stimulation
Dental Restorations
Diagnosis & Treatment of Sacroiliac Joint Pain
Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography
Drug Testing in Pain Management & Substance Use Disorder Treatment Settings
Drugs for Rare Diseases
Dry Needling of Myofascial Trigger Points
Dupixent® (dupilumab)
Durable Medical Equipment
Durable Medical Equipment Repair/Replacement (Excluding Wheelchairs)
Dynamic Spinal Visualization & Vertebral Motion Analysis
Egrifta®
(tesamorelin)
Electrical Bone Growth Stimulation of the Appendicular Skeleton
Electrical Stimulation Devices
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Endovascular Therapies for Extracranial Vertebral Artery Disease
Epidermal Growth Factor Receptor (EGFR) Inhibitors
Erythropoiesis-Stimulating Agents
Excessively High Cost Drug Products with Lower Cost Alternatives
Extracorporeal Membrane Oxygenation for Adult Conditions
Extracorporeal Photopheresis
Extracorporeal Shock Wave Treatment for Plantar Fasciitis
& Other Musculoskeletal Conditions
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
Facet
Arthroplasty
Facet Joint Denervation
Focal Treatments for Prostate Cancer
Functional Neuromuscular Electrical Stimulation
Fundus Photography
Gastric
Electrical Stimulation
Gender Reassignment Surgery
Gene Therapy for Inherited Retinal Dystrophy
General Anesthesia & Facility Services Related to Dental Treatment
General Medical Necessity Criteria for Companion Diagnostics Related to Drug Approval
Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients
Growth Hormone Therapy
Hearing Aids (Excludes Implantable Devices)
Hematopoietic Cell Support for Chronic Lymphocytic Leukemia & Small Lymphocytic Lymphoma
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
Hematopoietic Cell Transplantation for Autoimmune Diseases
Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors & Ependymoma
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 Non-Hodgkin Lymphomas
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
Hematopoietic Cell Transplantation for Primary Amyloidosis
Hematopoietic Cell Transplantation for Solid Tumors of Childhood
Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia
Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
Hematopoietic Cell Transplantation for Treatment of Chronic Myelogenous Leukemia
Hemlibra® (emicizumab-kxwh)
Hepatitis C Antiviral
Therapy
Herceptin® (trastuzumab) & Other HER2 Inhibitors
Hereditary Angioedema
Hetlioz® (tasimelteon)
Home Enteral Nutrition
Hospital Beds
& Accessories
Hyperbaric Oxygen
Therapy
Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Select Intra-Abdominal & Pelvic Malignancies
IL-5
Inhibitors
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
Imlygic® (talimogene laherparepvec)
Immune Checkpoint Inhibitors
Immune Globulin Therapy
Immune Prophylaxis for Respiratory Syncytial Virus
Implantable Bone Conduction & Bone-Anchored Hearing Aids
Intestinal & Multivisceral Organ Transplant Surgery
In Vitro Chemoresistance & Chemosensitivity Assays
Increlex® (mecasermin); Recombinant Human Insulin-Like Growth Factor-1
Infertility & Reproductive Services
Injectable Clostridial Collagenase for Fibroproliferative Disorders
Interspinous & Interlaminar Stabilization/Distraction Devices (Spacers)
Intra-Articular Hyaluronan Injections for Osteoarthritis
Intracellular Micronutrient Analysis
Intraoperative Neurophysiologic Monitoring
Intravenous Anesthetics for the Treatment of Chronic Pain & Psychiatric Disorders
Islet Transplantation
Kalydeco® (ivacaftor), Orkambi® (lumacaftor / ivacaftor), and Symdeko™ (tezacaftor / ivacaftor)
Keratoprosthesis
Knee Arthroplasty in Adults
Knee
Arthroscopy in Adults
Knee Orthoses (Braces), Ankle-Foot-Orthoses, and Knee-Ankle-Foot-Orthoses
Lipid
Apheresis
Lumbar
Spinal
Fusion
Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomyys
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease
Magnetic Resonance–Guided Focused Ultrasound
Management of Opioid Therapy
Mastectomy for Gynecomastia
Measurement of Serum Antibodies to Infliximab, Adalimumab, and Vedolizumab
Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits
Medical Necessity Criteria for Compounded Medications
Medical Necessity Criteria for Medication Safety: Controlled Substances Utilization Service Program
Medical Necessity Criteria for Pharmacy Edits
Medical Necessity Exception Criteria for Closed Formulary Benefits & for Dispense as Written (DAW) Exception Reviews
Medical Policy & Clinical Guidelines: Definitions & Procedures
Meniscal Allografts & Other Meniscal Implants
Microprocessor-Controlled & Powered Prostheses for the Lower Limb
Microwave Tumor Ablation
Migraine & Cluster Headache Medications
Miscellaneous Oncology Drugs
Mobile Cardiac Outpatient Telemetry
Molecular Genetic Testing
Monoclonal Antibodies for the Treatment of B-Cell Malignancies
Monoclonal Antibodies for the Treatment of Lymphoma
mTOR Kinase Inhibitors
Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis
Multimarker Serum Testing Related to Ovarian Cancer
Multiple Receptor Tyrosine Kinase Inhibitors
Myalept® (metreleptin)
Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure
Myoelectric Prosthetic & Orthotic Components for the Upper Limb
Non-covered Services & Procedures
Nonpharmacologic Treatment of Rosacea
Nulojix® (belatacept) for Adults
Occipital Nerve Stimulation
Off-Label Use of Drugs and Biologic Agents
Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification
Orthodontic Services for Treatment of Congenital Craniofacial Anomalies
Orthognathic Surgery
Orthopedic Applications of Platelet-Rich Plasma
Orthopedic Applications of Stem Cell Therapy (Including Allografts & Bone Substitutes Used with Autologous Bone Marrow)
Orthoptic & Vision Therapy, Visual Perceptual Training, Vision Restoration Therapy, & Neurovisual Rehabilitation
Oscillatory Devices for the Treatment of Cystic Fibrosis & Other Respiratory Conditions
Outpatient Pulmonary Rehabilitation
Panniculectomy & Excision of Redundant Skin
Patient Lifts, Seat Lifts & Standing Devices
Patient-Specific Cutting Guides for Joint Arthroplasty
Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Percutaneous Vertebroplasty & Sacroplasty
Periodontics
Peripheral Subcutaneous Field Stimulation
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
Pharmacologic Treatment of Idiopathic Pulmonary Fibrosis
Pharmacologic Treatment of Neuropathy, Fibromyalgia, and Seizure Disorders
Pharmacotherapy of Arthropathies
Pharmacotherapy of Cushing’s Disease and Acromegaly
Pharmacotherapy of Inflammatory Bowel Disorder
Pharmacotherapy of Miscellaneous Autoimmune Diseases
Pharmacotherapy of Multiple Sclerosis
Pharmacotherapy of Perinatal/Infantile and Juvenile-Onset Hypophosphatasia (HPP)
Pharmacotherapy of Spinal Muscular Atrophy (SMA)
Pharmacotherapy of Thrombocytopenia
Pharmacotherapy of Type I &Type II Diabetes Mellitus
Phosphoinositide 3-kinase (PI3K) Inhibitors
Physical Medicine & Rehabilitation – Physical Therapy & Medical Massage Therapy
Placental & Umbilical Cord Blood as a Source of Stem Cells
Plasma-based Proteomic Screening in the Management of Pulmonary Nodules
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Power Operated Vehicles (Scooters) (excluding motorized wheelchairs)
Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities
Preventive
Care
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
Prolotherapy
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
Prostate Cancer Targeted Therapies
Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer
Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer
Psychiatric Evaluations in Inpatient & Residential Behavioral Health Treatment
Pulsed Radiofrequency
Quantitative Assay for Measurement of HER2 Total Protein Expression & HER2 Dimers
Radicava® (edaravone)
Radioembolization for Primary & Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma
Recombinant & Autologous Platelet-Derived Growth Factors for Wound Healing & Other Non-Orthopedic Conditions
Reconstructive Breast Surgery/Management of Breast Implants
Reduction Mammaplasty for Breast-Related Symptoms
Repository Corticotropin Injection
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
Review for Coverage in the Absence of a Medical Policy, Pharmacy Policy, or Utilization Management Guideline
Rhinoplasty
Right-to-Try Laws & Coverage of Services
Rituxan® (rituximab): Non-oncologic & Miscellaneous Uses
Routine Foot Care Services
Routine Vision Care
Sacral Nerve Neuromodulation/Stimulation
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus & Other Connective Tissue Diseases
Single Photon Emission Computed Tomography (SPECT) for Non-cardiac Indications
Sinus
Surgery
Site of Service: Infusion Drugs & Biologic Agents
Site of Service: Select Surgical Procedures
Skilled Home Health Care Services
Skilled Hourly Nursing Care in the Home
Skilled Nursing Facility (SNF): Admission, Continued Stay, and Transition of Care Guideline
Sleep Disorder Management
Solid Organ Transplants
Soliris® (eculizumab)
Speech Therapy
Sphenopalatine Ganglion Block for Headache
Spinal Cord & Dorsal Root Ganglion Stimulation
Stem Cell Therapy for Peripheral Arterial Disease
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy
Subtalar Arthroereisis
Surgery for Groin Pain in Athletes
Surgical Treatments for Lymphedema
Surgical Treatment of Snoring & Obstructive Sleep Apnea Syndrome
Technology
Review
Temporo-mandibular Joint Disorder
Testing Serum Vitamin D Level
Therapeutic Radiopharm-aceuticals in Oncology
Three-Dimensional Printed Orthopedic Implants
Total Artificial Hearts & Implantable Ventricular Assist Devices
Transcatheter Aortic Valve Implantation for Aortic Stenosis
Transcatheter Arterial Chemoembolization as a Treatment for Primary or Metastatic Liver Malignancies
Transcatheter Mitral Valve Repair
Transcatheter Pulmonary Valve Implantation
Transcranial Magnetic Stimulation as a Treatment of Depression & Other Psychiatric/Neurologic Disorders
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Treatment of Hyperhidrosis
Treatment of Pulmonary Hypertension
Treatment of Varicose Veins/Venous Insufficiency
Trogarzo™ (ibalizumab)
Tumor Treating Fields Therapy
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Ultrasound Accelerated Fracture Healing Device
Upper Gastrointestinal (UGI) Endoscopy for Adults
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors & Other Angiogenesis Inhibitors in Oncology Patients
Vagus Nerve Blocking Therapy for Treatment of Obesity
Vagus Nerve Stimulation
Venclexta® (venetoclax) BCL-2 Inhibitor
Vertebral Axial Decompression
Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement
Wheelchairs (Manual or Motorized)
Xolair® (omalizumab)
™