|
Management of Dry Eye Syndrome and Meibomian Gland Dysfunction (e.g., LipiFlow)
Open a PDF
9.01.19
|
2025-12-23 |
Eyes (Ophthalmology)
|
|
Aqueous Drainage Devices (Stents and Shunts) for Glaucoma
Open a PDF
9.01.18
|
2026-01-27 |
Eyes (Ophthalmology)
|
|
Intraocular Lens (IOL) Implants
Open a PDF
9.01.14
|
2025-10-22 |
Eyes (Ophthalmology)
|
|
Vision Therapy
Open a PDF
9.01.04
|
2025-11-25 |
Eyes (Ophthalmology)
|
|
Therapies (Speech, Physical and Occupational)
Open a PDF
8.01.24
|
2025-11-25 |
Therapy & Rehabilitation
|
|
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction
Open a PDF
8.01.22
|
2026-04-20 |
Nervous Systems (Neurology)
|
|
Light and Laser Therapies for Dermatologic Conditions
Open a PDF
8.01.21
|
2025-10-22 |
Skin (Dermatology)
|
|
Cardiac Rehabilitation
Open a PDF
8.01.14
|
2025-10-22 |
Therapy & Rehabilitation
|
|
Prolotherapy (Effective 2026-10-15)
Open a PDF
8.01.10
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Prolotherapy
Open a PDF
8.01.10
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Photodynamic Therapy for Malignant Disease
Open a PDF
8.01.06
|
2026-04-28 |
Cancer Treatment (Oncology)
|
|
Extracorporeal Photochemotherapy/Photopheresis
Open a PDF
8.01.01
|
2025-10-22 |
Skin (Dermatology)
|
|
Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes
Open a PDF
7.03.03
|
2026-03-24 |
Drug / Medications
|
|
Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Services
Open a PDF
7.03.01
|
2026-07-31 |
Anesthesiology
|
|
Lung and Lobar Lung Transplant
Open a PDF
7.02.10
|
2026-04-20 |
Transplants
|
|
Liver Transplantation
Open a PDF
7.02.07
|
2025-11-25 |
Transplants
|
|
Heart & Heart/Lung Transplant
Open a PDF
7.02.06
|
2026-07-21 |
Transplants
|
|
Small Bowel and Multivisceral Transplants in Adults and Children
Open a PDF
7.02.05
|
2026-03-24 |
Transplants
|
|
Kidney Transplantation
Open a PDF
7.02.04
|
2026-04-20 |
Transplants
|
|
Autologous Hematopoietic Stem Cell Transplantation (Auto-HSCT)
Open a PDF
7.02.03
|
2026-03-13 |
Transplants
|
|
Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT)
Open a PDF
7.02.02
|
2026-04-22 |
Transplants
|
|
Pancreas Transplant: (Pancreas Transplant Alone, Pancreas Transplant after Kidney Transplant, Simultaneous Pancreas Kidney Transplant): Islet Cell Transplant
Open a PDF
7.02.01
|
2026-03-24 |
Transplants
|
|
Sinus Excision/Destruction, Implants, and Repair
Open a PDF
7.01.99
|
2025-12-23 |
Ear, Nose & Throat (Otorhinolaryngology)
|
|
Lumbar Microdiscectomy (Effective 2026-10-15)
Open a PDF
7.01.98
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Lumbar Microdiscectomy
Open a PDF
7.01.98
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Hip Arthroplasty (Effective 2026-10-15)
Open a PDF
7.01.96
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Hip Arthroplasty
Open a PDF
7.01.96
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) (Effective 2026-10-15)
Open a PDF
7.01.95
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing)
Open a PDF
7.01.95
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Sacroiliac Joint Fusion or Stabilization (Effective 2026-10-15)
Open a PDF
7.01.93
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Sacroiliac Joint Fusion or Stabilization
Open a PDF
7.01.93
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Left Atrial Appendage Closure Devices
Open a PDF
7.01.92
|
2025-09-25 |
Heart & Blood Vessels (Cardiovascular)
|
|
Heart Failure Management Devices
Open a PDF
7.01.91
|
2026-03-13 |
Heart & Blood Vessels (Cardiovascular)
|
|
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) (Effective 2026-10-15)
Open a PDF
7.01.89
|
2026-07-15 |
Digestive System (Gastroenterology)
|
|
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)
Open a PDF
7.01.89
|
2026-07-15 |
Digestive System (Gastroenterology)
|
|
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty)
Open a PDF
7.01.85
|
2026-08-25 |
Ear, Nose & Throat (Otorhinolaryngology)
|
|
Gender Affirming Surgery and Treatments for Commercial and Medicare Advantage Members
Open a PDF
7.01.84
|
2026-05-27 |
Miscellaneous
|
|
Artificial Cervical Intervertebral Disc (Effective 2026-10-15)
Open a PDF
7.01.80
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Artificial Cervical Intervertebral Disc
Open a PDF
7.01.80
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Implantable Bone Conduction Hearing Aids
Open a PDF
7.01.77
|
2026-04-20 |
Ear, Nose & Throat (Otorhinolaryngology)
|
|
Metal-on-Metal Total Hip Resurfacing (Effective 2026-10-15)
Open a PDF
7.01.74
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Metal-on-Metal Total Hip Resurfacing
Open a PDF
7.01.74
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Lysis of Epidural Adhesions (Effective 2026-10-15)
Open a PDF
7.01.73
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Lysis of Epidural Adhesions
Open a PDF
7.01.73
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Radioembolization (TARE) for Hepatic Tumors
Open a PDF
7.01.69
|
2026-02-23 |
Radiation Treatment
|
|
Gastric Electrical Stimulation
Open a PDF
7.01.64
|
2026-01-27 |
Digestive System (Gastroenterology)
|
|
Artificial Lumbar Intervertebral Disc (Effective 2026-10-15)
Open a PDF
7.01.63
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Artificial Lumbar Intervertebral Disc
Open a PDF
7.01.63
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Osteochondral Grafting of the Knee (Effective 2026-10-15)
Open a PDF
7.01.59
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Osteochondral Grafting of the Knee
Open a PDF
7.01.59
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Pacemakers and Cardiac Resynchronization Therapy (CRT) Devices
Open a PDF
7.01.58
|
2026-03-13 |
Heart & Blood Vessels (Cardiovascular)
|
|
Blepharoplasty and Brow Ptosis Repair
Open a PDF
7.01.55
|
2026-03-24 |
Cosmetic / Reconstructive Surgery
|
|
Abdominoplasty, Panniculectomy, and Lipedema Reduction Surgery
Open a PDF
7.01.53
|
2026-05-27 |
Cosmetic / Reconstructive Surgery
|
|
Spinal Cord Stimulation / Dorsal Column Stimulation (Effective 2026-10-15)
Open a PDF
7.01.51
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Spinal Cord Stimulation / Dorsal Column Stimulation
Open a PDF
7.01.51
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Varicose Vein Treatments
Open a PDF
7.01.47
|
2025-10-22 |
Cosmetic / Reconstructive Surgery
|
|
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
Open a PDF
7.01.45
|
2026-03-24 |
Digestive System (Gastroenterology)
|
|
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation (Effective 2026-10-15)
Open a PDF
7.01.42
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation
Open a PDF
7.01.42
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Surgical Management of Sleep Disorders
Open a PDF
7.01.41
|
2026-01-27 |
Sleep Medicine
|
|
Reduction Mammaplasty (Mammoplasty)
Open a PDF
7.01.39
|
2026-07-21 |
Cosmetic / Reconstructive Surgery
|
|
Autologous Chondrocyte Implantation (ACI) (Effective 2026-10-15)
Open a PDF
7.01.38
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Autologous Chondrocyte Implantation (ACI)
Open a PDF
7.01.38
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions
Open a PDF
7.01.35
|
2026-08-25 |
Skin (Dermatology)
|
|
Erectile Dysfunction
Open a PDF
7.01.30
|
2025-10-22 |
Urinary System (Genitourinary)
|
|
Bariatric and Metabolic Surgery
Open a PDF
7.01.29
|
2026-06-16 |
Digestive System (Gastroenterology)
|
|
MAZE Procedures for Atrial Fibrillation and Flutter
Open a PDF
7.01.27
|
2026-06-25 |
Heart & Blood Vessels (Cardiovascular)
|
|
Cochlear Implants and Auditory Brainstem Implants
Open a PDF
7.01.26
|
2026-04-22 |
Ear, Nose & Throat (Otorhinolaryngology)
|
|
Deep Brain Stimulation
Open a PDF
7.01.23
|
2026-04-20 |
Nervous Systems (Neurology)
|
|
Bulking Agents for Treatment of Urinary or Fecal Incontinence
Open a PDF
7.01.22
|
2026-03-24 |
Urinary System (Genitourinary)
|
|
Dental and Oral Care under Medical Plans
Open a PDF
7.01.21
|
2026-05-27 |
Dental
|
|
Peroral Endoscopic Myotomy (POEM) Procedures
Open a PDF
7.01.120
|
2026-02-13 |
Digestive System (Gastroenterology)
|
|
Injectable Fillers for Dermal and Laryngeal Conditions
Open a PDF
7.01.119
|
2025-09-25 |
Miscellaneous
|
|
Lumbar Fusion (Effective 2026-10-15)
Open a PDF
7.01.117
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Lumbar Fusion
Open a PDF
7.01.117
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Facet Joint Injections/ Medial Branch Blocks (Effective 2026-10-15)
Open a PDF
7.01.116
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Facet Joint Injections/ Medial Branch Blocks
Open a PDF
7.01.116
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Epidural Steroid Injections (Effective 2026-10-15)
Open a PDF
7.01.115
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Epidural Steroid Injections
Open a PDF
7.01.115
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Ventricular Assist Device (VAD) and Total Artificial Heart (TAH)
Open a PDF
7.01.114
|
2026-03-24 |
Heart & Blood Vessels (Cardiovascular)
|
|
Lumbar Decompression (Effective 2026-10-15)
Open a PDF
7.01.113
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Lumbar Decompression
Open a PDF
7.01.113
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Intradiscal Procedures (Effective 2026-10-15)
Open a PDF
7.01.112
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Intradiscal Procedures
Open a PDF
7.01.112
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Thermal Ablation for Solid Tumor Treatment
Open a PDF
7.01.111
|
2026-08-25 |
Cancer Treatment (Oncology)
|
|
Angioplasty and Stenting of Extracranial, Intracranial and Vertebral Arteries
Open a PDF
7.01.110
|
2025-12-23 |
Nervous Systems (Neurology)
|
|
Cosmetic and Reconstructive Procedures
Open a PDF
7.01.11
|
2025-09-25 |
Cosmetic / Reconstructive Surgery
|
|
Transcatheter Heart Valve Procedures
Open a PDF
7.01.109
|
2026-05-27 |
Heart & Blood Vessels (Cardiovascular)
|
|
Gender Reassignment/Gender Affirming Surgery and Treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) Members
Open a PDF
7.01.105
|
2026-03-20 |
Miscellaneous
|
|
Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
Open a PDF
7.01.104
|
2026-08-04 |
Urinary System (Genitourinary)
|
|
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
Open a PDF
7.01.103
|
2026-05-27 |
Nervous Systems (Neurology)
|
|
Balloon Dilation of the Eustachian Tube
Open a PDF
7.01.101
|
2026-07-21 |
Ear, Nose & Throat (Otorhinolaryngology)
|
|
Pain Management Techniques for Knee Pain
Open a PDF
7.01.100
|
2026-07-21 |
Bone & Joints (Orthopedic)
|
|
Sacral Nerve Stimulation
Open a PDF
7.01.10
|
2025-12-16 |
Nervous Systems (Neurology)
|
|
Implantable Cardioverter Defibrillator (ICD)
Open a PDF
7.01.06
|
2026-03-13 |
Heart & Blood Vessels (Cardiovascular)
|
|
Vagus Nerve Stimulation and Vagus Nerve Blocking Therapy
Open a PDF
7.01.05
|
2026-08-25 |
Nervous Systems (Neurology)
|
|
Focal Therapies for Prostate Cancer Treatment
Open a PDF
7.01.01
|
2026-08-25 |
Urinary System (Genitourinary)
|
|
Positron Emission Tomography (PET) – Head Imaging
Open a PDF
6.01.47
|
2026-02-13 |
Radiology (x-rays) & Imaging
|
|
Magnetic Resonance Imaging (MRI) of the Prostate (Effective 2026-10-15)
Open a PDF
6.01.46
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Magnetic Resonance Imaging (MRI) of the Prostate
Open a PDF
6.01.46
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Tumor-Treatment Fields Therapy
Open a PDF
6.01.45
|
2026-04-20 |
Cancer Treatment (Oncology)
|
|
Radiopharmaceuticals for the Treatment of Cancer
Open a PDF
6.01.44
|
2025-09-30 |
Cancer Treatment (Oncology)
|
|
Electromagnetic Navigation Bronchoscopy
Open a PDF
6.01.40
|
2026-01-27 |
Lungs (Respiratory)
|
|
Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA) (Effective 2026-10-15)
Open a PDF
6.01.34
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA)
Open a PDF
6.01.34
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Brachytherapy After Breast-Conserving Surgery
Open a PDF
6.01.30
|
2025-11-25 |
Radiation Treatment
|
|
Positron Emission Tomography (PET) Oncologic Applications (Effective 2026-10-15)
Open a PDF
6.01.29
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Positron Emission Tomography (PET) Oncologic Applications
Open a PDF
6.01.29
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Capsule Endoscopy
Open a PDF
6.01.27
|
2025-10-22 |
Digestive System (Gastroenterology)
|
|
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty (Effective 2026-10-15)
Open a PDF
6.01.17
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty
Open a PDF
6.01.17
|
2026-07-15 |
Bone & Joints (Orthopedic)
|
|
Brachytherapy or Radioactive Seed Implantation for Prostate Cancer
Open a PDF
6.01.16
|
2025-12-31 |
Radiation Treatment
|
|
Computed Tomography (CT) for Coronary Calcium Scoring
Open a PDF
6.01.13
|
2026-02-13 |
Radiology (x-rays) & Imaging
|
|
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy
Open a PDF
6.01.12
|
2025-11-14 |
Radiation Treatment
|
|
Proton Beam Radiation Therapy
Open a PDF
6.01.11
|
2026-08-25 |
Radiation Treatment
|
|
Positron Emission Tomography (PET) - Non-Oncologic Applications (Effective 2026-10-15)
Open a PDF
6.01.07
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Positron Emission Tomography (PET) - Non-Oncologic Applications
Open a PDF
6.01.07
|
2026-07-15 |
Radiology (x-rays) & Imaging
|
|
Bone Densitometry/Bone Density Studies
Open a PDF
6.01.05
|
2026-08-25 |
Radiology (x-rays) & Imaging
|
|
Magnetic Resonance Spectroscopy (MRS)
Open a PDF
6.01.03
|
2026-02-13 |
Radiology (x-rays) & Imaging
|
|
Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome
Open a PDF
4.01.10
|
2025-09-25 |
Women's Health (Obstetrics & Gynecology)
|
|
Assisted Reproductive Technologies
Open a PDF
4.01.05
|
2026-01-15 |
Women's Health (Obstetrics & Gynecology)
|
|
Prenatal Genetic Testing
Open a PDF
4.01.03
|
2026-03-17 |
Genetic Disease (Inherited Disease)
|
|
Endometrial Ablation
Open a PDF
4.01.01
|
2026-02-23 |
Women's Health (Obstetrics & Gynecology)
|
|
Neuropsychological and Psychological Testing
Open a PDF
3.01.24
|
2026-04-28 |
Behavioral Health (Psychiatry/Psychology)
|
|
Gender Affirming Behavioral Health and Medical Services
Open a PDF
3.01.22
|
2026-08-25 |
Miscellaneous
|
|
Level of Care Criteria for Inpatient, Residential, Partial Hospital, and Intensive Outpatient Mental Health Services for Adults and Children
Open a PDF
3.01.21
|
2026-04-20 |
Behavioral Health (Psychiatry/Psychology)
|
|
Continuing Day Treatment Programs
Open a PDF
3.01.20
|
2026-04-20 |
Behavioral Health (Psychiatry/Psychology)
|
|
Treatment of Gambling Disorder and Other Repetitive Behaviors
Open a PDF
3.01.19
|
2026-02-23 |
Behavioral Health (Psychiatry/Psychology)
|
|
Partial Hospitalization for Substance Use Disorders
Open a PDF
3.01.18
|
2026-08-25 |
Behavioral Health (Psychiatry/Psychology)
|
|
Ketamine for the Treatment of Psychiatric Disorders
Open a PDF
3.01.13
|
2026-04-13 |
Behavioral Health (Psychiatry/Psychology)
|
|
Applied Behavior Analysis
Open a PDF
3.01.11
|
2026-06-25 |
Behavioral Health (Psychiatry/Psychology)
|
|
Transcranial Magnetic Stimulation and Cranial Electrotherapy Stimulation
Open a PDF
3.01.09
|
2026-01-27 |
Behavioral Health (Psychiatry/Psychology)
|
|
Genetic Testing for Thoracic Aortic Aneurysms/ Dissections and Connective Tissue Related Disorders
Open a PDF
2.02.61
|
2025-10-15 |
Genetic Disease (Inherited Disease)
|
|
Germline Genetic Testing for Hereditary Cancers
Open a PDF
2.02.60
|
2026-04-20 |
Genetic Disease (Inherited Disease)
|
|
Molecular Testing in the Management of Pulmonary Nodules
Open a PDF
2.02.58
|
2025-10-22 |
Lab Tests (pathology)
|
|
Circulating Tumor DNA for Management of Cancer (Liquid Biopsy)
Open a PDF
2.02.56
|
2026-02-23 |
Lab Tests (pathology)
|
|
Laboratory Testing for Transplantation Rejection
Open a PDF
2.02.55
|
2026-07-21 |
Lab Tests (pathology)
|
|
Measurable Residual Disease (MRD) Assessment Testing
Open a PDF
2.02.54
|
2026-08-25 |
Lab Tests (pathology)
|
|
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms
Open a PDF
2.02.53
|
2026-03-24 |
Lab Tests (pathology)
|
|
Gene Expression Profiling for Cutaneous Melanoma
Open a PDF
2.02.52
|
2025-10-22 |
Cancer Treatment (Oncology)
|
|
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers
Open a PDF
2.02.51
|
2026-02-23 |
Genetic Disease (Inherited Disease)
|
|
Urine Drug Testing
Open a PDF
2.02.50
|
2025-12-29 |
Lab Tests (pathology)
|
|
Molecular Marker Testing of the Thyroid
Open a PDF
2.02.49
|
2025-11-25 |
Genetic Disease (Inherited Disease)
|
|
Laboratory Testing for the Screening and Management of Prostate Cancer
Open a PDF
2.02.48
|
2025-12-29 |
Genetic Disease (Inherited Disease)
|
|
Testing for the Use of Biologic Therapeutics for the Treatment of Inflammatory Disorders
Open a PDF
2.02.47
|
2025-11-25 |
Lab Tests (pathology)
|
|
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
Open a PDF
2.02.46
|
2025-09-30 |
Genetic Disease (Inherited Disease)
|
|
Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/ Intellectual Disability or Autism Spectrum Disorder
Open a PDF
2.02.42
|
2025-11-25 |
Genetic Disease (Inherited Disease)
|
|
Predictive Testing for Pancreatic Cancer
Open a PDF
2.02.39
|
2025-12-23 |
Lab Tests (pathology)
|
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Genetic Testing for Cardiac Ion Channelopathies
Open a PDF
2.02.38
|
2026-05-27 |
Genetic Disease (Inherited Disease)
|
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Pharmacogenetics
Open a PDF
2.02.30
|
2026-04-14 |
Genetic Disease (Inherited Disease)
|
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Genetic Assay of Tumor Tissue to Determine Prognosis and Treatment of Breast Cancer
Open a PDF
2.02.27
|
2026-04-20 |
Genetic Disease (Inherited Disease)
|
|
Non-Invasive Prenatal Testing
Open a PDF
2.02.25
|
2026-08-25 |
Lab Tests (pathology)
|
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Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
Open a PDF
2.02.19
|
2025-11-25 |
Lab Tests (pathology)
|
|
Genetic Testing for Cystic Fibrosis
Open a PDF
2.02.17
|
2026-07-21 |
Genetic Disease (Inherited Disease)
|
|
Lab Testing for Alzheimer’s Disease
Open a PDF
2.02.16
|
2026-06-25 |
Genetic Disease (Inherited Disease)
|
|
Inflammatory Markers of Coronary Artery Disease Risk
Open a PDF
2.02.15
|
2025-07-24 |
Lab Tests (pathology)
|
|
Urinary Tumor Markers for Bladder and Urothelial Cancers
Open a PDF
2.02.12
|
2026-07-21 |
Lab Tests (pathology)
|
|
Genetic Testing for Inherited Disorders
Open a PDF
2.02.03
|
2025-12-23 |
Genetic Disease (Inherited Disease)
|
|
Bioimpedance Devices for Detection and Management of Breast Cancer Related Lymphedema
Open a PDF
2.01.52
|
2026-01-27 |
Miscellaneous
|
|
Colorectal Cancer Screening and Surveillance
Open a PDF
2.01.51
|
2026-03-24 |
Digestive System (Gastroenterology)
|
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Fecal Microbiota Transplantation
Open a PDF
2.01.48
|
2025-09-25 |
Digestive System (Gastroenterology)
|
|
Extracorporeal Shock Wave Therapy (ESWT) for Muscoloskeletal Conditions and Soft Tissue Wounds
Open a PDF
2.01.31
|
2026-03-24 |
Bone & Joints (Orthopedic)
|
|
Sleep Studies
Open a PDF
2.01.28
|
2026-01-27 |
Sleep Medicine
|
|
Evoked Potentials
Open a PDF
2.01.27
|
2026-05-27 |
Nervous Systems (Neurology)
|
|
Platelet Rich Plasma and Growth Factor Treatments
Open a PDF
2.01.24
|
2026-01-27 |
Skin (Dermatology)
|
|
Allergy Testing
Open a PDF
2.01.10
|
2026-07-21 |
Ear, Nose & Throat (Otorhinolaryngology)
|
|
Hyperbaric Oxygen Therapy (HBOT)
Open a PDF
2.01.07
|
2026-07-21 |
Miscellaneous
|
|
Cardiac Event Monitors
Open a PDF
2.01.03
|
2026-07-21 |
Heart & Blood Vessels (Cardiovascular)
|
|
Periodontal Maintenance
Open a PDF
13.01.05
|
2026-07-21 |
Dental
|
|
Periodontal Scaling and Root Planing
Open a PDF
13.01.04
|
2026-07-21 |
Dental
|
|
Dental Inlays and Onlays
Open a PDF
13.01.03
|
2026-07-21 |
Dental
|
|
Dental Crowns and Veneers
Open a PDF
13.01.02
|
2026-07-21 |
Dental
|
|
Dental Implants
Open a PDF
13.01.01
|
2026-07-21 |
Dental
|
|
Private Rooms
Open a PDF
12.01.06
|
2025-11-25 |
Miscellaneous
|
|
New/Emerging Technology & Services
Open a PDF
11.01.27
|
2025-11-25 |
Miscellaneous
|
|
New/Emerging Technology and Services Code List
Open a PDF
11.01.27
|
2026-04-30 |
Miscellaneous
|
|
Home Birth by Certified Nurse Midwives
Open a PDF
11.01.23
|
2025-10-22 |
Women's Health (Obstetrics & Gynecology)
|
|
Skilled Nursing Facility Care / Level of Care Criteria
Open a PDF
11.01.21
|
2026-07-21 |
Miscellaneous
|
|
Interfacility Transfer of a Registered Inpatient
Open a PDF
11.01.18
|
2026-03-24 |
Miscellaneous
|
|
Temporomandibular Joint Disorders (TMJD)
Open a PDF
11.01.17
|
2026-02-13 |
Bone & Joints (Orthopedic)
|
|
Medically Necessary Services
Open a PDF
11.01.15
|
2025-10-22 |
Miscellaneous
|
|
Out-of-Network Services
Open a PDF
11.01.13
|
2026-01-27 |
Miscellaneous
|
|
Comfort, Convenience, or Custodial Services
Open a PDF
11.01.11
|
2025-12-23 |
Miscellaneous
|
|
Clinical Trials
Open a PDF
11.01.10
|
2026-01-13 |
Miscellaneous
|
|
Medical Response to Contamination from Terrorist Attacks
Open a PDF
11.01.09
|
2026-08-25 |
Miscellaneous
|
|
Ambulance: Air
Open a PDF
11.01.06
|
2026-03-24 |
Miscellaneous
|
|
Total Parenteral Nutrition (TPN) or Hyperalimentation
Open a PDF
11.01.04
|
2026-02-23 |
Food (Nutrition)
|
|
Experimental or Investigational Services
Open a PDF
11.01.03
|
2026-08-07 |
Miscellaneous
|
|
Emergency Care Services
Open a PDF
10.01.12
|
2026-03-24 |
Miscellaneous
|
|
Disability Determination for Extension of Benefits after Coverage Termination
Open a PDF
10.01.11
|
2026-08-25 |
Miscellaneous
|
|
Second Medical and Surgical Opinions
Open a PDF
10.01.10
|
2026-08-25 |
Miscellaneous
|
|
Coverage for Dependents with Disabilities
Open a PDF
10.01.08
|
2025-11-25 |
Miscellaneous
|
|
Ambulance: Land/Ground
Open a PDF
10.01.07
|
2026-03-24 |
Miscellaneous
|
|
Enteral Nutrition
Open a PDF
10.01.03
|
2026-02-23 |
Food (Nutrition)
|
|
Chiropractic Care
Open a PDF
10.01.02
|
2026-07-21 |
Chiropractic
|
|
Breast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy
Open a PDF
10.01.01
|
2026-08-25 |
Cosmetic / Reconstructive Surgery
|
|
Specialized Neuromodulation for Specific Conditions
Open a PDF
1.01.62
|
2026-08-24 |
Durable Medical Equipment & Supplies
|
|
Non-Invasive Surface Electrical Stimulation for Pain and Rehabilitation
Open a PDF
1.01.61
|
2026-05-27 |
Durable Medical Equipment & Supplies
|
|
Implantable and Invasive Neuromodulation Systems
Open a PDF
1.01.60
|
2026-05-27 |
Durable Medical Equipment & Supplies
|
|
Electromagnetic and Pulsed Field Stimulation
Open a PDF
1.01.59
|
2026-05-27 |
Durable Medical Equipment & Supplies
|
|
Cranial and Auricular Neuromodulation
Open a PDF
1.01.58
|
2026-05-27 |
Durable Medical Equipment & Supplies
|
|
Home Non-Invasive Positive Pressure Ventilation (NIPPV) Devices for Respiratory Insufficiency and Failure (Effective 2026-10-15)
Open a PDF
1.01.57
|
2026-07-15 |
Sleep Medicine
|
|
Specialty Enclosure Bed Systems
Open a PDF
1.01.56
|
2026-02-13 |
Durable Medical Equipment & Supplies
|
|
Bone Growth Stimulators
Open a PDF
1.01.53
|
2026-04-20 |
Bone & Joints (Orthopedic)
|
|
Vitrectomy Chair/ Face-Down Positioning System
Open a PDF
1.01.52
|
2026-04-20 |
Durable Medical Equipment & Supplies
|
|
Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis
Open a PDF
1.01.51
|
2025-09-25 |
Durable Medical Equipment & Supplies
|
|
Standing Devices and Gait Trainers
Open a PDF
1.01.46
|
2026-02-23 |
Durable Medical Equipment & Supplies
|
|
Home Automatic External Defibrillators (AEDs) and Wearable Cardioverter Defibrillators (WCDs)
Open a PDF
1.01.42
|
2026-06-25 |
Heart & Blood Vessels (Cardiovascular)
|
|
Foot Orthotics
Open a PDF
1.01.41
|
2026-07-21 |
Feet (Podiatry)
|
|
Negative Pressure Wound Therapy (Vacuum-Assisted Closure)
Open a PDF
1.01.38
|
2025-09-25 |
Skin (Dermatology)
|
|
Cranial Orthotics
Open a PDF
1.01.32
|
2025-11-14 |
Children's Health (Pediatrics)
|
|
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes
Open a PDF
1.01.30
|
2025-12-23 |
Diabetes (Endocrinology)
|
|
Orthotics
Open a PDF
1.01.25
|
2026-05-15 |
Bone & Joints (Orthopedic)
|
|
Cryotherapy (Cold Therapy) Devices
Open a PDF
1.01.21
|
2026-06-25 |
Bone & Joints (Orthopedic)
|
|
Pelvic Floor Electrical Stimulation as a Treatment for Urinary or Fecal Incontinence
Open a PDF
1.01.19
|
2026-03-24 |
Urinary System (Genitourinary)
|
|
External Prosthetic Devices
Open a PDF
1.01.18
|
2026-05-15 |
Miscellaneous
|
|
Powered Compression Devices/Lymphedema Pumps
Open a PDF
1.01.17
|
2026-01-15 |
Durable Medical Equipment & Supplies
|
|
Wheelchairs and Power Operated Vehicles (POVs)
Open a PDF
1.01.16
|
2026-08-25 |
Durable Medical Equipment & Supplies
|
|
Airway Clearance Devices
Open a PDF
1.01.15
|
2025-12-16 |
Lungs (Respiratory)
|
|
Patient Lifts (e.g., Hoyer, Saralift, Seat Lift, Chair Mechanisms, and Ceiling Lifts)
Open a PDF
1.01.08
|
2025-07-24 |
Home Care
|
|
Medical Management Obstructive Sleep Apnea (OSA)
Open a PDF
1.01.07
|
2025-11-14 |
Lungs (Respiratory)
|
|
Positive Airway Pressure Devices CPAP BiPAP APAP and Noninvasive Positive Pressure Ventilators (NIV)
Open a PDF
1.01.06
|
2026-07-15 |
Sleep Medicine
|
|
Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) Devices (Effective 2026-10-15)
Open a PDF
1.01.06
|
2026-07-15 |
Sleep Medicine
|
|
Augmentative and Alternative Communication Systems (e.g., Speech-generating Devices)
Open a PDF
1.01.03
|
2026-08-25 |
Durable Medical Equipment & Supplies
|
|
Continuous Passive Motion Device (CPM) in the Home Setting
Open a PDF
1.01.02
|
2025-10-22 |
Durable Medical Equipment & Supplies
|
|
Durable Medical Equipment (DME) and Devices, Standard and Non-Standard
Open a PDF
1.01.00
|
2026-08-25 |
Durable Medical Equipment & Supplies
|
