ACG-UHC Demonstration Project

Breast Repair/Reconstruction Not Following Mastectomy

Brineura™ (Cerliponase

Alfa)

Bronchial Thermoplasty

Buprenorphine (Probuphine® & Sublocade™)

Cardiovascular Disease Risk Tests

Carrier Testing for Genetic Diseases

Chemosensitivity & Chemoresistance Assays in Cancer

Corneal Hysteresis & Intraocular Pressure Measurement

Cosmetic & Reconstructive Procedures

Crysvita (burosumab-twza)

Cytological Examination of Breast Fluids for Cancer Screening

Deep Brain & Cortical Stimulation

Denosumab (Prolia® & Xgeva®)

Discogenic

Pain

Treatment

Embolization of Ovarian & Iliac Veins for Pelvic Congestion Syndrome

Emergency Health Care Services & Urgent Care Center Services

Entyvio® (Vedolizumab)

Enzyme Replacement Therapy

Epidural Steroid & Facet Injections for Spinal Pain

Epiduroscopy, Epidural Lysis of Adhesions

& Functional Anesthetic Discography

Erythropoiesis Stimulating Agents (ESA)

Gastric

Electrical Stimulation

(GES)

Maximum Dosage

Mechanical Stretching Devices

Meniscus

Implant & Allograft

Mifeprex® (Mifepristone)

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD)

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, & Treatment Decisions

Nerve Graft to Restore Erectile Function During Radical Prostatectomy

Neurophysiologic Testing &

Monitoring

Transcranial Magnetic Stimulation (TMS)

Transpupillary Thermotherapy

Trogarzo (ibalizumab-

uiyk)

Umbilical Cord Blood Harvesting

& Storage for Future Use

Unicondylar Spacer Devices for Treatment of

Pain/Disability

Vaccines

Vagus Nerve Stimulation

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