ACG-Premera Blue Demonstration Project

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

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)

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