Internal Medical Policy Search

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Policy ID Title Last Updated Category
1.01.00 Durable Medical Equipment (DME) - Standard and Non-Standard, Home Medical Equipment Open a PDF 2020-09-21 Durable Medical Equipment & Supplies
1.01.01 Electrical Stimulation: Transcutaneous Electrical Nerve (TENS), Percutaneous Electrical Nerve (PENS), H-Wave and Interferential Stimulators (IFS), Percutaneous Neuromodulation Therapy, Bionicare® Open a PDF 2020-07-17 Durable Medical Equipment & Supplies
1.01.02 Continuous Passive Motion Device (CPM) in the Home Setting Open a PDF 2020-03-04 Durable Medical Equipment & Supplies
1.01.03 Augmentative and Alternative Communication Systems: AAC, Dynavox, Introtalker, VoiceMate, Walker Talker, Say-It-All, Speech Generating Devices (SGD) Open a PDF 2020-03-10 Durable Medical Equipment & Supplies
1.01.04 Blood Pressure Monitoring, Automated, Ambulatory Open a PDF 2020-03-04 Heart & Blood Vessels (Cardiovascular)
1.01.05 Home and Community Oxygen Therapy: Long Term Oxygen Therapy (LTOT), High Altitude Stimulation Test (HAST), Oxygen Concentrator, Portable Oxygen Open a PDF 2020-03-27 Home Care
1.01.06 Positive Airway Pressure Devices: CPAP, BiPAP, APAP, DPAP, C-FLex Open a PDF 2020-09-21 Durable Medical Equipment & Supplies
1.01.07 Oral Appliances for the Treatment of Sleep Related Breathing Disorders: Mandibular Repositioning Device, Nocturnal Airway Patency Appliance (NAPA), Tongue Retaining Device Open a PDF 2020-04-20 Lungs (Respiratory)
1.01.08 Patient Lifts (e.g., Hoyer, Saralift), Seat Lift Chair Mechanisms and Ceiling Lifts Open a PDF 2020-07-17 Home Care
1.01.12 Home Exercise/Physical Therapy Equipment (e.g., Home Gym, Jacuzzi) Open a PDF 2020-02-20 Home Care
1.01.14 Surgical Stockings (e.g., Gradient Compression/GCS, Jobst, Sigvaris, TEDs) and Compression Garments (e.g., Arm Assist, Belisse Compressure Bra, Lymphedema, Mastectomy, Circaid, Juzo, Reid Sleeves) Open a PDF 2020-09-21 Durable Medical Equipment & Supplies
1.01.15 Airway Clearance Devices: Oscillatory Devices - ABI Vest, Acapella, Flutter Valve, Lung Flute®, ThAIRapy Vest; Mechanical Percussors and Assisted Cough Devices - Cofflator, Cough-Alator, In-Exsufflator Open a PDF 2020-03-10 Lungs (Respiratory)
1.01.16 Wheelchairs and Power Operated Vehicles (POVs) (e.g., Scooters) Open a PDF 2020-07-17 Durable Medical Equipment & Supplies
1.01.17 Pneumatic Compression Devices/Lymphedema Pump/Sleeve (e.g., Flexitouch™) Open a PDF 2020-05-13 Durable Medical Equipment & Supplies
1.01.18 External Prosthetic Devices: C-leg, Intelligent prosthesis, microprocessor-controlled lower limbs, Ossur Rheo, Vacuum-assisted-socket system (VASS) Open a PDF 2020-03-27 Miscellaneous
1.01.19 Pelvic Floor Electrical Stimulation as a Treatment for Urinary or Fecal Incontinence Open a PDF 2020-07-17 Urinary System (Genitourinary)
1.01.21 Cryotherapy, Cold Therapy, Ice Therapy Open a PDF 2020-07-17 Bone & Joints (Orthopedic)
1.01.24 Phototherapy/Light Therapy for Seasonal Affective Disorder (SAD) Open a PDF 2020-03-12 Behavioral Health (Psychology)
1.01.25 Orthotics (e.g., OttoBock E-Mag Active KAFO, OttoBock SensorWalk Electronic KAFO, MYOMO mPower 1000 arm brace) Open a PDF 2020-05-13 Bone & Joints (Orthopedic)
1.01.30 CGMS, Continuous glucose monitor, DexCom STS, Freestyle Navigator, Interstitial glucose monitoring, MiniMed CGMS® System Gold™, MiniMed Guardian® Real-Time, MiniMed Paradigm Revel® Real-Time system, DexCom G5®,Wrist glucose monitor, Continuous subcutaneous insulin infusion, CSII, Insulin pump therapy Open a PDF 2020-05-07 Diabetes (Endocrinology)
1.01.31 End-Diastolic Pneumatic Compression (e.g., Circulator Boot) Open a PDF 2020-05-07 Heart & Blood Vessels (Cardiovascular)
1.01.32 Cranial Orthotics/Helmet for Asymmetry (e.g., Dynamic Orthotic Cranioplasty, DOC) Open a PDF 2020-03-10 Children's Health (Pediatrics)
1.01.33 Home Phototherapy for Hyperbilirubinemia (e.g., Biliblanket, Bili Lights) Open a PDF 2020-09-21 Children's Health (Pediatrics)
1.01.35 Dynamic Adjustable Braces/Joint Extension Device (e.g., Dynasplint™, EMPI Advance™, LMB Proglide™, Ultraflex™) Open a PDF 2020-03-27 Bone & Joints (Orthopedic)
1.01.38 Negative Pressure Wound Therapy, PICO™ system, SNaP® system, Topical Negative Pressure Therapy, Vacuum Assisted Closure Therapy, NPWT Open a PDF 2020-03-05 Skin (Dermatology)
1.01.39 Breast Pumps Open a PDF 2020-05-13 Durable Medical Equipment & Supplies
1.01.41 Foot Orthotics, Arch Supports, Shoe Inserts Open a PDF 2020-07-24 Feet (Podiatry)
1.01.42 Home Automatic External Defibrilator (AEDs) and Wearable Defibrillator Vests (WCDs): HeartStart, LIFECOR Open a PDF 2020-06-11 Heart & Blood Vessels (Cardiovascular)
1.01.44 Home Prothrombin Time Monitor (e.g., Acusure™, CoaguChek®, International Normalized Ratio [INR], Prothrombin Time [PTT], Protime, Rubicon®) Open a PDF 2020-07-17 Home Care
1.01.46 Standing Devices and Gait Trainers, Stander Open a PDF 2020-03-27 Durable Medical Equipment & Supplies
1.01.47 Cervical Traction Devices (e.g., HomeTrac Deluxe, Saunders Cervical HomeTrac, Hydraulic, Over-The-Door, Pneumatic Cervical, Pronex) Open a PDF 2020-05-13 Durable Medical Equipment & Supplies
1.01.48 Neuromuscular Electrical Stimulation (FNS, NMES, TES, VitalStim®) Open a PDF 2020-09-03 Durable Medical Equipment & Supplies
1.01.49 Telemedicine and Telehealth Open a PDF 2020-04-21 Home Care
1.01.50 Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices Open a PDF 2020-07-17 Bone & Joints (Orthopedic)
1.01.51 Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis: Triple Play VT®, Venodyne, VascuTherm2 Open a PDF 2020-09-25 Durable Medical Equipment & Supplies
1.01.52 Vitrectomy Chair/ Face-Down Positioning System Open a PDF 2020-05-13 Durable Medical Equipment & Supplies
1.01.53 Bone Growth Stimulators for the Appendicular Skeleton Open a PDF 2020-04-26 Bone & Joints (Orthopedic)
10.01.01 Breast Reconstruction Surgery Open a PDF 2020-09-21 Cosmetic / Reconstructive Surgery
10.01.02 Chiropractic Care Open a PDF 2020-05-13 Chiropractic
10.01.03 Enteral Formula/Nutrition, Enteral Therapy, Probiotics, Tube Feeding Open a PDF 2020-03-27 Food (Nutrition)
10.01.05 Prostate Cancer Screening, Detection and Monitoring (e.g., Digital Rectal Exam - DRE, PCA3Plus, Prostate Specific Antigen - PSA, Prostatic Acid Phosphatase - Male PAP Test) Open a PDF 2020-09-03 Urinary System (Genitourinary)
10.01.07 Ambulance: Land/Ground Open a PDF 2020-05-13 Miscellaneous
10.01.08 Coverage for Dependents with Disabilities Open a PDF 2020-03-12 Miscellaneous
10.01.09 Early Intervention Services Open a PDF 2020-03-04 Children's Health (Pediatrics)
10.01.10 Second Medical and Second Surgical Opinions, Confirmatory Consultation Open a PDF 2020-05-13 Miscellaneous
10.01.11 Disability Determination for Extension of Benefits after Contract Termination Open a PDF 2020-09-21 Miscellaneous
10.01.12 Emergency Care Services Open a PDF 2020-05-13 Miscellaneous
11.01.01 Medical/Non-Surgical Weight Management Programs and Services, Intensive/High Intensity lifestyle counseling Open a PDF 2020-03-06 Miscellaneous
11.01.03 Experimental or Investigational Services Open a PDF 2020-03-27 Miscellaneous
11.01.04 Total Parenteral Nutrition (TPN), Intradialytic Parenteral Nutrition (IDPN), Intraperitoneal Nutrition (IPN), or Hyperalimentation Open a PDF 2020-03-27 Food (Nutrition)
11.01.06 Ambulance: Air Open a PDF 2020-05-13 Miscellaneous
11.01.09 Medical Response to Contamination from Terrorist Attacks: Biological (e.g., Anthrax, Germ Warfare, Plague, Smallpox), Chemical, Radiation Open a PDF 2020-09-21 Miscellaneous
11.01.10 Clinical Trials Open a PDF 2020-02-19 Miscellaneous
11.01.11 Comfort, Convenience, Custodial or Cosmetic Services Open a PDF 2020-02-19 Miscellaneous
11.01.13 Out of Area/Out of Network Services Open a PDF 2020-09-21 Miscellaneous
11.01.15 Medically Necessary Services Open a PDF 2020-02-20 Miscellaneous
11.01.17 Temporomandibular Joint (TMJ) Disease Open a PDF 2020-02-20 Bone & Joints (Orthopedic)
11.01.18 Interfacility (Hospital-to-Hospital, Inpatient, Interhospital) Transfer of a Registered Inpatient Open a PDF 2020-05-13 Miscellaneous
11.01.21 Skilled Nursing Facility (SNF) Care for Medicare Advantage Members Open a PDF 2020-03-27 Miscellaneous
11.01.23 Home Birth by Certified Nurse Midwives Open a PDF 2020-03-04 Women's Health (Obstetrics & Gynecology)
11.01.26 Sex Specific Services, Gender Dysphoria, Gender Identity Disorder, GID, transgender, transsexualism Open a PDF 2020-07-17 Behavioral Health (Psychology)
12.01.06 Private Rooms Open a PDF 2020-02-20 Miscellaneous
13.01.01 Dental Implants Open a PDF 2020-07-17 Dental
13.01.02 Dental Crowns and Veneers Open a PDF 2020-07-17 Dental
13.01.03 Dental Inlays and Onlays Open a PDF 2020-07-17 Dental
13.01.04 Periodontal Scaling and Root Planing Open a PDF 2020-07-17 Dental
13.01.05 Periodontal Maintenance Open a PDF 2020-07-17 Dental
2.01.02 Signal Averaged Electrocardiogram (SAECG) Open a PDF 2020-02-24 Heart & Blood Vessels (Cardiovascular)
2.01.03 Ambulatory Event Monitor (AEM): Ambulatory Electrocardiographic (AECG) Devices, Cardiac Event Detection (CED), CardioNet, Mobile Cardiac Outpatient Telemetry (MCOT), Ziopatch Open a PDF 2020-03-17 Heart & Blood Vessels (Cardiovascular)
2.01.07 Hyperbaric Oxygen Therapy (HBOT): Systemic or Topical, Topical Oxygen Wound Therapy (TOWT) Open a PDF 2020-06-11 Miscellaneous
2.01.09 Biofeedback, EMG Biofeedback Open a PDF 2020-03-06 Alternative Medicine
2.01.10 Allergy Testing (Allergen Specific IgE, Allergen Specific IgG, Challenge, Cytotoxic, Dipstick, Disk, Intracutaneous, Intradermal, Leukocyte Histamine Release, Mucous Membrane, Paddle, Patch, Percutaneous, Phadiatop, Prick, Provocation-Neutralization, RAST, Rinkel, Scratch, Serial Endpoint Titration, Skin End Point Titration, Skin) Open a PDF 2020-09-25 Ear, Nose & Throat (Otorhinolaryngology)
2.01.11 Allergen Immunotherapy: Injections. Sublingual Immunotherapy Open a PDF 2020-03-04 Ear, Nose & Throat (Otorhinolaryngology)
2.01.13 Computerized Motion Diagnostic Imaging (CMDI), Gait Analysis, Spinoscopy Open a PDF 2020-02-24 Bone & Joints (Orthopedic)
2.01.20 Posturography (e.g., Balance Test, Equitest) Open a PDF 2020-03-05 Ear, Nose & Throat (Otorhinolaryngology)
2.01.24 Growth Factors for Wound Healing and Other Conditions: Becaplermin, Platelet Derived Growth Factor (PDGF), Platelet Rich Plasma, Regranex Open a PDF 2020-02-24 Skin (Dermatology)
2.01.25 Hyperthermia as a Cancer Treatment: Extracorporeal Whole Body, Intraperitoneal, Local, Regional, Whole Body Open a PDF 2020-06-11 Cancer Treatment (Oncology)
2.01.26 Hypnosis Open a PDF 2020-03-12 Behavioral Health (Psychology)
2.01.27 Evoked Potentials: Auditory, Brainstem Auditory, Somatosensory, Visual and Intraoperative Monitoring of Evoked Potentials Open a PDF 2020-04-15 Nervous Systems (Neurology)
2.01.31 Extracorporeal Shock Wave Therapy (ESWT) for Muscoloskeletal Conditions and Soft Tissue Wounds: Lithotripsy, Orthotripsy, OssaTron®, EpoUltra®, SINOCUR®, Orbasone™, Orthospec™ Open a PDF 2020-04-15 Bone & Joints (Orthopedic)
2.01.34 Quantitative Sensory Testing (QST) Open a PDF 2020-03-12 Nervous Systems (Neurology)
2.01.35 Foot Care and Treatment of Mycotic Nails Open a PDF 2020-09-21 Feet (Podiatry)
2.01.36 Alopecia (e.g., Areata, Androgenic, Scarring), Baldness, Hair Loss Open a PDF 2020-02-19 Cosmetic / Reconstructive Surgery
2.01.38 Treatment of Hirsutism/Hypertrichosis (Hair Removal) (e.g., Electrolysis, Epilation) Open a PDF 2020-02-20 Cosmetic / Reconstructive Surgery
2.01.39 Auditory Processing Disorder (APD) Testing Open a PDF 2020-02-19 Ear, Nose & Throat (Otorhinolaryngology)
2.01.41 Measurement of Exhaled Markers of Airway Inflammation in Patients with Asthma: Exhaled Breath Condensate, Exhaled Nitric Oxide, Nioxx Open a PDF 2020-02-24 Lungs (Respiratory)
2.01.42 Immunizations/Vaccines (e.g., Hepatitis A, Hepatitis B, Human Papillomavirus [HPV, Cervarix, Gardasil], Meningococcal, Pneumococcal [Pneumovax 23, Prevnar], Rotavirus [Rotarix], Varicella [Varivax], Varicella Zoster [Zostavax]) Open a PDF 2020-06-11 Vaccines (Immunizations)
2.01.48 Fecal Bacteriotherapy, Fecal microbiota therapy (FMT), Fecal transfusion, Fecal transplant, Human probiotic infusion (HPI), Intestinal microbiotia Transplantation (IMT), Microbiome, Stool transplant Open a PDF 2020-03-12 Digestive System (Gastroenterology)
2.01.49 High Resolution Anoscopy (Anal Colposcopy) Open a PDF 2020-03-06 Digestive System (Gastroenterology)
2.01.50 Neuropsychological Testing Open a PDF 2020-02-20 Nervous Systems (Neurology)
2.01.51 Colorectal Cancer Screening, Cologuard, CT Colonography, FIT, gFOBT, virtual colonoscopy, fecal DNA, fecal occult blood test Open a PDF 2020-09-25 Digestive System (Gastroenterology)
2.01.52 Bioimpedance Devices for Detection and Managment of Lymphedema, bioelectrical impedance spectroscopy Open a PDF 2020-06-11 Miscellaneous
2.01.53 Neuropsychiatric Quantitative Encephalography in the Diagnosis of Attention Deficit/Hyperactivity Disorder (e.g., NEBA system) Open a PDF 2020-04-15 Nervous Systems (Neurology)
2.01.54 Developmental Evaluation and Testing Open a PDF 2020-02-20 Children's Health (Pediatrics)
2.02.02 Non-Invasive Helicobacter Pylori (H Pylori) Testing: HpSA, Urea Breath Test Open a PDF 2020-06-11 Lab Tests (pathology)
2.02.03 Genetic Testing for Inherited Disorders: Alpha-1-Antitrypsin Deficiency, ALS - Amyotrophic Lateral Sclerosis, Lou Gehrig's Disease, Angelman Syndromes, Becker Muscular Dystrophy, CADASIL, Charcot-Marie-Tooth Huntington's Disease, Congenital Adrenal Hyperplasia, Duchenne Muscular Dystrophy - DMD, Dystonia, Factor V, Fanconi Anemia, Fragile X syndrome, Gaucher Disease, Hemophilia A and B, Myotonic Dystrophy, Neurofibromatosis, Phenylketonuria - PKU, Prader Willi, Sickle Cell, Tay-Sachs Disease, Thalassemia Open a PDF 2020-09-03 Genetic Disease (Inherited Disease)
2.02.04 Cervical Cancer Screening and Human Papilloma Virus (HPV) Testing (e.g., Cervista™, Cobas® HPV test, DNA with PAP, HPV, HPV DNA testing, Human Papillomavirus, HC 2, Hybrid Capture 2, Pap/ Papanicolaou smear: Direct visualization, Monolayer, Optical; FocalPoint™, MonoPrep Pap Test (MPPT), PapSure®, Speculite®, Speculoscopy, SurePath, ThinPrep®) Open a PDF 2020-04-15 Women's Health (Obstetrics & Gynecology)
2.02.05 Genetic Testing for Hereditary Hemochromatosis Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.06 Genetic Testing for Hereditary BRCA Mutations: BART test, BRCA1, BRCA2, CHEK2 Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.07 Genetic Testing for Germline Mutations of the RET Proto Oncogene in Medullary Carcinoma of the Thyroid Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.10 Serum Tumor Markers for Diagnosis and Management of Cancer (AFP, CA-125, CA-19-9, CA-15-3, CA 27, CA 29, CEA, HCG, Proteomic) Open a PDF 2020-03-11 Lab Tests (pathology)
2.02.11 Genetic Testing for Inherited Susceptibility to Colorectal Cancer: Familial Adenomatous Polyposis (FAP), Hereditary Nonpolyposis Colorectal Cancer (HNPCC), COLARIS®, Microsatellite instability (MSI), MYH-associated polyposis(MAP) Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.12 Urinary Tumor Markers for Bladder Cancer: AccuDx, BTA Stat™, Fibrin/Fibrinogen Degradation Products (FDP), ImmunoCyt, Nuclear Matrix Protein (NMP-22), Urinary Bladder Cancer Antigen (UBC Rapid Test) Open a PDF 2020-09-03 Lab Tests (pathology)
2.02.15 Inflammatory Markers of Coronary Artery Disease Risk Open a PDF 2020-07-17 Lab Tests (pathology)
2.02.16 Genetic Testing for Familial Alzheimer's Disease Open a PDF 2020-06-11 Genetic Disease (Inherited Disease)
2.02.17 Genetic Testing for Cystic Fibrosis: CF Transmembrane Conductance Regulator (CFTR) Open a PDF 2020-09-03 Genetic Disease (Inherited Disease)
2.02.18 Biochemical Markers of Bone Turnover (e.g., Collagen Cross Links, Cross Laps, ITCP, N-telopeptides, NTx, Pyrilinks) Open a PDF 2020-09-03 Lab Tests (pathology)
2.02.19 Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease, Anti-neutrophil Cytoplasmic antibodies, ANCA, ASCA, Serologic Markers Open a PDF 2020-03-11 Lab Tests (pathology)
2.02.25 First Trimester Screening for Down Syndrome (e.g., Cell-Free Fetal DNA, Harmony™, Free Beta PAPP-A, MaterniT21™, Non-invasive Prenatal Testing, Nuchal Translucency, Panorama™, Verify®) Open a PDF 2020-04-15 Lab Tests (pathology)
2.02.27 Genetic Assay of Tumor Tissue to Determine Prognosis of Breast Cancer (Blueprint®, OncotypeDX™, MammaPrint®, Targetprint®) Open a PDF 2020-09-03 Genetic Disease (Inherited Disease)
2.02.29 Cardiovascular Disease Risk Assessment - Laboratory Evaluation of Lipids: Apolipoprotein A-1, B, and E, Lipoprotein (a) Enzyme Immunoassay Open a PDF 2020-03-10 Lab Tests (pathology)
2.02.30 Genotyping Cytochrome P450 (CYP450) for Drug Metabolism: Amplichip Open a PDF 2020-03-17 Genetic Disease (Inherited Disease)
2.02.31 Her-2 Testing in Invasive Breast Cancer Using Fluorescence in Situ Hybridization (FISH) or Immunohistochemistry (IHC) Assays: HercepTest, PathVysion, INFORM®, FISH pharmdX) Open a PDF 2020-04-15 Lab Tests (pathology)
2.02.33 Genotyping Cytochrome P450 2C9 (CYP2C9) and Vitamin K Epoxide Reductase Subunit CI (VKORC) That Affect Response to Warfarin Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.34 Genotyping Uridine Diphosphate Glycuronosyltransferase (UGT1A1) for Patients Treated with Irinotecan Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.35 Genotyping - Targeted Therapy for Non-Small Cell Lung Cancer (NSCLC) (e.g., EGFR, ALK and KRAS) Open a PDF 2020-03-17 Genetic Disease (Inherited Disease)
2.02.37 Genotyping or Phenotyping for Thiopurine Methyltransferase (TPMT) for Patients Treated with Azathioprine (6-MP), Inflammatory Bowel Disease Open a PDF 2020-02-24 Genetic Disease (Inherited Disease)
2.02.38 Genetic Testing for Cardiac Ion Channelopathies Open a PDF 2020-05-08 Genetic Disease (Inherited Disease)
2.02.39 Pathfinder TG® Molecular Testing: Redpath, Topographic Genotyping Open a PDF 2020-02-24 Lab Tests (pathology)
2.02.40 Anticoagulation Testing Open a PDF 2020-09-03 Lab Tests (pathology)
2.02.41 Genotyping - RAS Mutation Analysis in Metastatic Colorectal Cancer, BRAF, KRAS, NRAS, PIK3CA status, PTEN expression Open a PDF 2020-09-03 Genetic Disease (Inherited Disease)
2.02.42 Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/ Intellectual Disability or Autism Spectrum Disorder Open a PDF 2020-03-04 Genetic Disease (Inherited Disease)
2.02.43 Proteomics-Based Testing for the Evaluation of Ovarian (Adnexal) Masses: Ova1™ Open a PDF 2020-09-03 Lab Tests (pathology)
2.02.44 Genetic Testing for Susceptibility to Hereditary Cancers (PTEN, Cowden Syndrome, TP53, Li Fraumeni Syndrome, BreastNext, CancerNext, OvaNext, MyRisk Hereditary Cancer, Melaris, Prolaris, Panexia) Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.45 Screening for Vitamin D Deficiency Open a PDF 2020-09-25 Lab Tests (pathology)
2.02.46 Whole Exome and Whole Genome Sequencing for the Diagnosis of Genetic Disorders Open a PDF 2020-09-03 Genetic Disease (Inherited Disease)
2.02.47 Measurement of Serum Antibodies to Infliximab and Adalimumab: Anser™IFX, Anser™ADA Open a PDF 2020-03-18 Lab Tests (pathology)
2.02.48 Gene Expression Analysis for Prostate Cancer Management: Oncotype DX® Prostate, Prolaris® Open a PDF 2020-03-10 Genetic Disease (Inherited Disease)
2.02.49 Molecular Markers in Fine Needle Aspirates of the Thyroid: Afirma® GEC,ThyroSeq®, ThyGenX Thyroid Oncogene Panel Open a PDF 2020-09-03 Genetic Disease (Inherited Disease)
2.02.50 Urine Drug Testing, immunoassay, presumptive testing, confirmatory testing Open a PDF 2020-04-16 Lab Tests (pathology)
2.02.51 Molecular Panel Testing of Cancers to Identify Targetes Therapies, Molecular Panel Testing, Targeted Therapy, Foundation One, Caris Life Sciences, OmniSeq, PyroSeq Open a PDF 2020-03-11 Genetic Disease (Inherited Disease)
2.02.52 Gene Expression Profiling for Cutaneous Melanoma Open a PDF 2020-09-25 Cancer Treatment (Oncology)
3.01.02 Psychological Testing Open a PDF 2020-02-20 Behavioral Health (Psychology)
3.01.04 Medication Assisted Therapy (e.g., Buprenorphine, LAAM, Methadone Maintenance Treatment, Ultra-rapid Detoxification), Opioid treatment Open a PDF 2020-02-20 Behavioral Health (Psychology)
3.01.05 Behavioral Health Treatment of Family and Couples (Couples Therapy, Family Therapy) Open a PDF 2020-03-27 Behavioral Health (Psychology)
3.01.08 Group Therapy for Mental Health Open a PDF 2020-02-20 Behavioral Health (Psychology)
3.01.09 Transcranial Magnetic Stimulation: Deep TMS device, MagVita TMS, NeuroStar TMS device, rTMS, TMS Open a PDF 2020-02-24 Behavioral Health (Psychology)
3.01.10 Standard Dialectical Behavioral Therapy (DBT) Open a PDF 2020-09-21 Behavioral Health (Psychology)
3.01.11 Applied Behavioral Analysis for the Treatment of Autism Spectrum Disorders (ABA), Pervasive Developmental Disorders (PDD) Open a PDF 2020-03-12 Behavioral Health (Psychology)
3.01.13 Ketamine for the Treatment of Psychiatric Disorders Open a PDF 2020-02-24 Behavioral Health (Psychology)
3.01.15 Behavioral Health Treatment for Gender Dysphoria: Gender Identity Disorder (GID), Intersex, Transexualism Open a PDF 2020-09-21 Behavioral Health (Psychology)
3.01.17 Sex Offender Treatment Program Open a PDF 2020-09-21 Behavioral Health (Psychology)
3.01.18 Partial Hospitalization for Substance Use Disorders, Chemical Dependency Open a PDF 2020-09-21 Behavioral Health (Psychology)
3.01.19 Treatment of Gambling Disorder and Other Repetitive Behaviors Open a PDF 2020-07-17 Behavioral Health (Psychology)
3.01.20 Continuing Day Treatment Programs Open a PDF 2020-05-13 Behavioral Health (Psychology)
4.01.01 Endometrial Ablation: Her Option™, Hydro ThermAblator®, MEA System, Novasure™, Resectoscope, Rollerball, ThermaChoice®, Thermal Balloon Therapy Open a PDF 2020-03-17 Women's Health (Obstetrics & Gynecology)
4.01.03 Prenatal Genetic Testing Open a PDF 2020-07-17 Genetic Disease (Inherited Disease)
4.01.04 Uterine Artery Occlusion in the Treatment of Uterine Fibroids: Uterine Artery/Fibroid Embolization (UAE/UFE), Uterine Artery Coagulation Open a PDF 2020-04-20 Women's Health (Obstetrics & Gynecology)
4.01.05 Assisted Reproductive Technologies (ART) for Infertility: COMET Assay, Hylaluronan Binding Assay (HBA), Microsurgical Testicular Sperm Extraction (MicroTESE), Sperm DNA Integrity, Sperm Chromatin Structure Assay (SCSA®), Sperm DNA Fragmentation Assay (SDFA™), TUNEL Assay, Artificial or Intrauterine Insemination (AI, IUI), Microsurgical Epididymal Sperm Aspiration (MESA), Testicular Sperm Extraction (TESE), Direct Intra-Peritoneal Insemination (DIPI), Gamete Intrafallopian Transfer (GIFT), Intracytoplasmic Sperm Injection (ICSI), In-vitro Fertilization (IVF), Zygote Intrafallopian Transfer (ZIFT) Open a PDF 2020-03-04 Women's Health (Obstetrics & Gynecology)
4.01.07 Female Sterilization (e.g., Adiana®, Essure®, Tubal Ligation) Open a PDF 2020-03-04 Women's Health (Obstetrics & Gynecology)
5.01.15 Collagenase Clostridium Histolyticum (Xiaflex) for Fibroproliferative Disorders Open a PDF 2020-02-24 Drug / Medications
6.01.02 Nuclear Breast Imaging: Breast Specific Gamma Camera, BSGI, Gammagram, Miraluma, Radioimmunoscintigraphy, Scintigraphy, Scintimammography Open a PDF 2020-03-17 Radiology (x-rays) & Imaging
6.01.03 Magnetic Resonance Spectroscopy (MRS) Open a PDF 2020-03-17 Radiology (x-rays) & Imaging
6.01.05 Bone Densitometry/Bone Density Studies: DEXA Scan, Dual Photon Absorptiometry (DPA), Morphometric X-ray Absorptiometry, Single Photon Absorbtiometry (SPA), Ultrasound Measurement of the Heel Open a PDF 2020-03-06 Radiology (x-rays) & Imaging
6.01.07 Positron Emission Tomography (PET) Non-Oncologic Applications (FDG PET) Open a PDF 2020-04-15 Radiology (x-rays) & Imaging
6.01.09 Intravascular Ultrasound (IVUS) Open a PDF 2020-09-03 Heart & Blood Vessels (Cardiovascular)
6.01.11 Proton Beam Radiation (Charged Particle, Conformal) Open a PDF 2020-05-07 Radiation Treatment
6.01.12 Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Open a PDF 2020-07-17 Radiation Treatment
6.01.13 Coronary Calcium Scoring : Electron Beam CT (EBCT), Helical CT, Spiral CT, Multidetector Row CT (MDCT), Ultrafast CT, Cardiac Calcium Scoring Open a PDF 2020-03-17 Radiology (x-rays) & Imaging
6.01.15 Intravascular Brachytherapy, Endovascular Radiation Open a PDF 2020-09-03 Radiation Treatment
6.01.16 Brachytherapy or Radioactive Seed Implantation for Prostate Cancer Open a PDF 2020-03-04 Radiation Treatment
6.01.17 Percutaneous Vertebroplasty, Kyphoplasty, Mechanical Vertebral Augmentation (e.g., Kyphon Inflatable Bone Tamp) Open a PDF 2020-02-24 Bone & Joints (Orthopedic)
6.01.18 Transcranial Doppler Ultrasound Open a PDF 2020-03-12 Radiology (x-rays) & Imaging
6.01.19 Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening: Electron Beam Computed Tomography (EBCT), Helical CT, Low-Dose CT, Spiral CT Open a PDF 2020-02-24 Radiology (x-rays) & Imaging
6.01.22 Mammography: Digital Breast Tomosynthesis Open a PDF 2020-03-17 Radiology (x-rays) & Imaging
6.01.24 Intensity Modulated Radiation Therapy (IMRT) Open a PDF 2020-06-11 Radiation Treatment
6.01.26 Noninvasive Measurement of Cardiac Bioimpedance: Impedance Cardiography (ICG), Thoracic Electrical Bioimpedance (TEB) Open a PDF 2020-03-06 Heart & Blood Vessels (Cardiovascular)
6.01.27 Wireless Capsule Endoscopy/Imaging for Examination of the Gastrointestinal (GI) Tract: AGILE Patency Capsule, Given® Capsule Camera, PillCam SB, PillCam ESO Open a PDF 2020-09-25 Digestive System (Gastroenterology)
6.01.29 Positron Emission Tomography (PET), Oncologic Applications (FDG PET, FDG SPECT) Open a PDF 2020-06-11 Radiology (x-rays) & Imaging
6.01.30 Brachytherapy after Breast Conserving Surgery, as Boost with Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation: Accelerated Partial Breast Irradiation, APBI, Axxent, MammoSite Open a PDF 2020-03-04 Radiation Treatment
6.01.34 Cardiac Computed Tomographic Angiography (Calcium Scoring, Cardiac/Coronary CTA, Coronary Artery CTA, CT Angiography) Open a PDF 2020-03-06 Radiology (x-rays) & Imaging
6.01.35 Magnetic Resonance Imaging (MRI) of the Breast (Breast MRI, CAD MRI) Open a PDF 2020-06-11 Radiology (x-rays) & Imaging
6.01.37 CT (Computed Tomography) Perfusion Imaging, Dynamic Perfusion CT, Multimodal CT, Perfusion CT, Xenon-enhanced CT (XeCT) Open a PDF 2020-03-17 Radiology (x-rays) & Imaging
6.01.40 Electromagnetic Navigation Bronchoscopy (ENB) Open a PDF 2020-02-24 Lungs (Respiratory)
6.01.41 Positron Emission Tomography (PET) Cardiac Applications Open a PDF 2020-04-15 Radiology (x-rays) & Imaging
6.01.42 Obstetrical Ultrasound in the Second Trimester Open a PDF 2020-07-17 Women's Health (Obstetrics & Gynecology)
6.01.43 Superficial Radiation Therapy for Treatment of Skin Cancers (orthovoltage x-ray, SR-100, Xstrahl-100) Open a PDF 2020-09-25 Cancer Treatment (Oncology)
6.01.44 Radium-223 (Xofigo) for Treatment of Castration-Resistant Prostate Cancer Open a PDF 2020-06-11 Cancer Treatment (Oncology)
6.01.45 Tumor-Treatment Field Therapy for Glioblastoma: Electrical Field Therapy, NovoTTF-100™ Open a PDF 2020-04-15 Cancer Treatment (Oncology)
6.01.46 Magnetic Resonance Imaging Prostate/Multiparametric MRI Open a PDF 2020-03-12 Radiology (x-rays) & Imaging
7.01.01 Cryosurgery for Prostate Cancer Open a PDF 2020-07-17 Urinary System (Genitourinary)
7.01.03 Cryosurgical Tumor Ablation Open a PDF 2020-06-11 Cancer Treatment (Oncology)
7.01.05 Vagus Nerve Stimulation and Vagus Nerve Blocking Therapy Open a PDF 2020-07-17 Nervous Systems (Neurology)
7.01.06 Implantable Cardioverter-Defibrillator (AICD, Automatic ICD, Biventricular ICD, Dual-chamber ICD, ICD) Open a PDF 2020-05-07 Heart & Blood Vessels (Cardiovascular)
7.01.07 Ventricular Assist Devices (VAD, LVAD) Open a PDF 2020-09-03 Heart & Blood Vessels (Cardiovascular)
7.01.10 Sacral Nerve Stimulation for Pelvic Floor Dysfunction (Incontinence, Neuromodulation, Urinary Retention) Open a PDF 2020-09-25 Nervous Systems (Neurology)
7.01.100 Radiofrequency Knee Ablation/Denervation Open a PDF 2020-05-07 Bone & Joints (Orthopedic)
7.01.101 Balloon Dilation of the Eustachian Tube Open a PDF 2020-03-04 Ear, Nose & Throat (Otorhinolaryngology)
7.01.102 CIRCULATING TUMOR DNA for MANAGEMENT of CANCER (Liquid Biopsy) Open a PDF 2020-03-10 Lab Tests (pathology)
7.01.103 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 2020-05-08 Nervous Systems (Neurology)
7.01.104 Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) Open a PDF 2020-07-17 Urinary System (Genitourinary)
7.01.105 Gender Reassignment/Gender Affirming Surgery and Treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) Members Open a PDF 2020-09-21 Miscellaneous
7.01.11 Cosmetic and Reconstructive Procedures: Acne Cysts, Actinic Keratoses, Collagen Injection, Complexion Analysis, Dermatoscopy, Drionic, Face Lift, Hairplasty, Hair Transplant, Hyperhydrosis, Iontophoresis, Labiaplasty, Liposuction, Prolaryn, Tattoos, Voice Lift, Benign Skin Lesion Removal, Skin Tag Removal, Keloid Scars, Chemical Peel, Dermabrasion, Port Wine Stains, Rosacea, Vitiligo Open a PDF 2020-03-27 Cosmetic / Reconstructive Surgery
7.01.16 Automated Percutaneous and Endoscopic Discectomy: Stryker DeKompressor, Nucleotome, SpineJet Hydrodiscectomy Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.17 Percutaneous Intradiscal Electrothermal Annuloplasty Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.21 Dental and Oral Care under Medical Plans: Bone Cysts, Odontogenic Cysts, Oral Surgery Open a PDF 2020-07-17 Dental
7.01.22 Bulking Agents for Treatment of Urinary or Fecal Incontinence (Bovine Collagen, Carbon Coated Beads, Coaptite®, Contigen®, Durasphere, GAX, Macroplastique®, Microballoons, Solesta, Teflon® Injections, Uryx®) Open a PDF 2020-03-12 Urinary System (Genitourinary)
7.01.23 Deep Brain Stimulation Open a PDF 2020-03-17 Nervous Systems (Neurology)
7.01.26 Cochlear Implants and Auditory Brainstem Implants: Advanced Bionics® HiResolution Bionic Ear System (HiRes 90k), Cochlear® Nucleus 5, Med El® Maestro (Sonata or Pulsar), Nucleus 24® Auditory Brainstem Implant System, Nucleus® Hybrid™ L24 Cochlear Implant Open a PDF 2020-06-11 Ear, Nose & Throat (Otorhinolaryngology)
7.01.27 MAZE Procedures for Atrial Fibrillation and Flutter (e.g., Convergent procedure, COX III, Epicardial Maze, Hybrid, Mini Maze, Pulmonary Vein Isolation, Thoroscopic off-pump surgical ablation [TOPS]) Open a PDF 2020-05-07 Heart & Blood Vessels (Cardiovascular)
7.01.28 Transurethral Microwave Thermotherapy (e.g., Prostatron, Targis, Urowave System, CoreTherm, Prolieve, TMx-2000, TUMT) Open a PDF 2020-03-12 Urinary System (Genitourinary)
7.01.29 Surgical Management of Obesity: Adjustable Gastric Band, Bariatric Surgery, Biliopancreatic Diversion, Duodenal Switch, Endobarrier, Gastric Bypass, Gastric Plication, Imbrication, Lap Band, Restorative Obesity Surgery, Ednoluminal [ROSE], Roux-en-Y, Sleeve Gastrectomy, Stomach Stapling, TOGA, Transoral or Vertical Banded Gastroplasty Open a PDF 2020-03-12 Digestive System (Gastroenterology)
7.01.30 Erectile Dysfunction: Caverject, Edex, ErecAid, Intracavernosal Therapy, Intraurethral Therapy, MUSE (Medicated Urethral System for Erection), Penile Prosthesis, Penile Vein Ligation, Vacuum Erection Device, Vascular Revascularization Open a PDF 2020-09-21 Urinary System (Genitourinary)
7.01.31 Surgical Ventricular Reduction (e.g., Partial Ventriculectomy, Batista Procedure) Open a PDF 2020-05-08 Heart & Blood Vessels (Cardiovascular)
7.01.32 Radiofrequency Tumor Ablation Open a PDF 2020-09-25 Cancer Treatment (Oncology)
7.01.34 Transcatheter Closure Devices for Cardiac Defects: Amplatzer Septal Occluder, Angel Wing Device, Atrial Septal Detect Occluding System (ASDOS), CardioSEAL, HELEX, Sideris Buttoned Device Open a PDF 2020-09-03 Heart & Blood Vessels (Cardiovascular)
7.01.35 Bioengineered Tissue Products (Affinity™, AlloDerm®, AlloMax™, AlloSkin™, AlloWrap™, AmnioBand™, Amnioexcel®, AmnioMatrix®, Apligraf®, Artacent™ Wound, ArthroFlex™, Artificial skin, Avaulta Plus™, Biobrane®, Biobrane l®, Bioengineered skin, Biologic tissue, Biovance®, Clarix® Flo, Collamend, Conexa™, Cygnus Solo™, Cygnus Matrix™, Cygnus Max™,Cymetra®, Cytal™ Burn Matrix, Cytal™ Wound Matrix, DermACELL AWM™, DermaMatrix, DermaPure™, DermaSpan™, Dermavest™, Endoform Dermal Template™, ENDURAgen™, Epicel®, EpiCord™, EpiFix, Excellagen®, E-Z Derm™, FlexHD®, GammaGraft, Grafix® CORE, Grafix® PRIME, GraftJacket®, GraftJacket® Xpress, Graftskin, Guardian, hMatrix®, Hyalomatrix®, Integra™, Integra™ Bilayer Wound® Matrix, Integra™ Dermal Regeneration Matrix®, Integra™ FlowMiroderm®, Flowable Wound® Matrix, InteguPly™, Interfyl™, Laserskin, MariGen, Mediskin®, Neoform, Neox®, Neox 1K, Neox® Flo, NuShield™, OASIS® Wound Matrix, OASIS® Burn Matrix, OASIS® Ultra, Omnigraft™, Orcel™, Orthoadapt, PalinGen® - Membrane, Hydromembrane, Flow, and SportFlow, Pelvicol, Pelvisoft, Permacol™, Primatrix, PuraPly, Restore, Revitalon™, Skin substitute, StrataGraft, Strattice™, SurgiMend®, TenSIX™, TheraSkin®, Tissuemend, TranZgraft, TruSkin™, Veritas® Collagen Matrix, XCM Biological Tissue Matrix) Open a PDF 2020-06-11 Skin (Dermatology)
7.01.38 Autologous Chrondrocyte Implantation (e.g., Carticel®, Matrix-induced ACI, MACI, Minced cartilage, Neocartilage, Scaffold-induced ACI) Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.39 Reduction Mammaplasty/ Breast Reduction Open a PDF 2020-09-21 Cosmetic / Reconstructive Surgery
7.01.40 Bone Growth Stimulators (e.g., Electrical, Osteogenic, Sonic Accelerated Fracture Healing System - SAFHS, Ultrasonic) Open a PDF 2020-09-21 Bone & Joints (Orthopedic)
7.01.41 Surgical Management of Sleep Disorders/Sleep Apnea: Airvance®, Atrial overdrive pacing, Aura6000 System, CAPSO, Encore™, HGNS®, Hypoglossal Nerve Stimulation, Inspire II Upper Airway Stimulation System, LAUP, Pillar™, Repose™, Snoreplasty, Somnoplasty, UPPP Open a PDF 2020-04-15 Sleep Medicine
7.01.42 Radiofrequency Facet Denervation Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.45 Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD): ELF, EndoCinch, Endoluminal Fundoplication, Endoluminal Gastroplication, Enteryx, EsophyX, Gatekeeper, Plexiglas Microspheres, NDO Plicator System, Radiofrequency Esophageal Treatment, Stretta) Open a PDF 2020-04-15 Digestive System (Gastroenterology)
7.01.47 Varicosities/Varicose Veins, Treatment Alternatives to Vein Stripping and Ligation (e.g., Ambulatory, Stab or Transilluminated Powered Phlebectomy, ClariVein®, Endoluminal Radiofrequency Ablation, Endovenous Laser Ablation, Mechanochemical Endovenous Ablation, MOCA, Sclerotherapy, Varithena™, Venaseal™,VNUS) Open a PDF 2020-09-25 Cosmetic / Reconstructive Surgery
7.01.48 Placental and Umbilical Cord Blood as a Source of Stem Cells Open a PDF 2020-09-03 Transplants
7.01.51 Spinal Cord/Dorsal Column Stimulation Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.52 Isolated Limb Perfusion and Infusion (Alkeran, L-PAM, Melphalan, Tumor Necrosis Factor) Open a PDF 2020-03-04 Cancer Treatment (Oncology)
7.01.53 Abdominoplasty and Panniculectomy (e.g., Belt Lipectomy, Lipectomy, Tummy Tuck) Open a PDF 2020-05-13 Cosmetic / Reconstructive Surgery
7.01.55 Blepharoplasty/Eyelid Surgery with or without Levator Muscle Advancement (Pseudoptosis Surgery, Ptosis Surgery, Brow Lift) Open a PDF 2020-05-13 Cosmetic / Reconstructive Surgery
7.01.58 Cardiac Resynchronization Therapy (Biventricular Pacemakers) for the Treatment of Heart Failure (Bioimpedance, Dual Chamber Pacemaker) Open a PDF 2020-09-03 Heart & Blood Vessels (Cardiovascular)
7.01.59 Osteochondral Grafting (Allograft, Autograft): Chondrofix®, Mosaicplasty, OATS Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.60 Extracranial Carotid and Vertebral Artery Angioplasty and Stents, Percutaneous Transluminal Angioplasty (PTA), Carotid Stenosis Open a PDF 2020-04-15 Heart & Blood Vessels (Cardiovascular)
7.01.62 Intervertebral Disc Decompression: Laser (Laser Discectomy) and Radiofrequency Coblation (Disc Nucleoplasty™) Techniques Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.63 Artificial Lumbar Intervertebral Disc (e.g.,ActivL®,Bryan, Charité, ProDisc, ) Open a PDF 2020-02-24 Bone & Joints (Orthopedic)
7.01.64 Gastric Electrical Stimulation and Gastric Pacing Open a PDF 2020-03-06 Digestive System (Gastroenterology)
7.01.65 Artificial Hearts Open a PDF 2020-07-17 Heart & Blood Vessels (Cardiovascular)
7.01.66 Fecal Incontinence, Radiofrequency Treatment (Secca procedure) Open a PDF 2020-03-12 Digestive System (Gastroenterology)
7.01.69 Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors (SIR-Spheres, Theraspheres), Transarterial Raioembolization (TARE) Open a PDF 2020-09-25 Radiation Treatment
7.01.70 Angioplasty of Intracranial Atherosclerotic Stenoses with or without Stenting (e.g., Percutaneous Transluminal Angioplasty, Neurolink® System, Wingspan™ Stent) Open a PDF 2020-03-17 Nervous Systems (Neurology)
7.01.71 Surgical Ventricular Restoration (SVR): DOR Procedure, Surgical Anterior Endocardial Restoration (SAVER), Ventricular Remodeling Open a PDF 2020-04-20 Heart & Blood Vessels (Cardiovascular)
7.01.73 Lysis of Epidural Adhesions, Adhesiolysis, Epidurolysis,Neurolysis, Racz procedure Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.74 Total Hip Resurfacing, Metal-on-Metal Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.75 Interspinous and Interlaminar Stabilization/Distraction Implants (e.g., Coflex®, Interspinous Spacer, Spinal Distraction, Superion®, X STOP) Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.76 Manipulation Under Anesthesia (MUA), Manipulation under Joint Anesthesia (MUJA), Manipulation Under Sedation (MUS) Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.77 Implantable Bone Conduction Hearing Aids, Bone Anchored Hearing Aid (BAHA®), OBC bone anchored hearing aid system, Ponto Pro Open a PDF 2020-06-11 Ear, Nose & Throat (Otorhinolaryngology)
7.01.78 Peptide Receptor Radionuclide Therapy (PRRT, PRRNT): Receptor-Mediated Radiotherapy, Radiolabeled Nuclide Therapy, Somatostatin Analog, 90Y-DOTATOC, 177Lu-DOTA0, Tyr3, 90Y-DOTA0 Open a PDF 2020-09-25 Cancer Treatment (Oncology)
7.01.80 Artificial Cervical Intervertebral Discs (e.g., Bryan, Mobi-C, PCM [Porous Coated Motion] Cervical Disc®, Prestige®, ProDisc®, Secure-C) Open a PDF 2020-02-24 Bone & Joints (Orthopedic)
7.01.81 Endovascular Repair (Coil Embolization) of Intracranial Aneurysms - Enterprise Stent, Guglielmi Coil, Neuroform Stent, Pipeline Embolization Device (PEI), Transcatheter Intracranial Embolization Open a PDF 2020-05-07 Nervous Systems (Neurology)
7.01.83 Minimally Invasive Techniques for Lumbar Interbody Fusion: Anterior Lumbar(ALIF), Axial Lumbar (AxiaLIF), Direct Lateral (DLIF), Extreme Lateral (XLIF), Laparoscopic Anterior Lumbar (LALIF), Posterior Lumbar (PLIF), Transforaminal Lumbar (TLIF) Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.84 Gender Reassignment Surgery: Gender Dysphoria, Gender Identity Disorder (GID), Genital Correction Surgery, Genital Reassignment Surgery, Genital Reconstruction, Gender Realignment Surgery, Gender Confirmation Surgery, Intersex, Transsexualism, Transsexual Surgery Open a PDF 2020-07-17 Miscellaneous
7.01.85 Sinus Ostial Dilation for Treatment of Chronic Sinusitis (e.g., Balloon Sinuplasty), catheter sinusotomy Open a PDF 2020-06-11 Ear, Nose & Throat (Otorhinolaryngology)
7.01.86 Plugs for Fistula Repair Open a PDF 2020-03-17 Digestive System (Gastroenterology)
7.01.87 Spinal Injections (Epidural and Facet Injections) for Pain Management : Medial Branch Block Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.88 Bronchial Thermoplasty (e.g., Alair® System) Open a PDF 2020-04-20 Lungs (Respiratory)
7.01.89 Magnetic Esophageal Ring for the Treatment of Gastroesophageal Reflux (GERD): Esophageal Sphincter Device, LINX™ System, Magnetic Sphincter Augmentation Open a PDF 2020-03-17 Digestive System (Gastroenterology)
7.01.90 Lumbar Fusion for Adults, Degenerative Disc Disease, Disc herniation, Lumbar arthrodesis, Scoliosis, Spinal stenosis, spondylodesis, spondylosyndesis, spondylolisthesis Open a PDF 2020-02-24 Bone & Joints (Orthopedic)
7.01.91 Implantable Cardiac Hemodynamic Monitoring for Heart Failure: CardioMEMS HF, Pulmonary artery pressure sensor, Wireless hemodynamic monitor Open a PDF 2020-03-12 Heart & Blood Vessels (Cardiovascular)
7.01.92 Percutaneous Left Atrial Appendage Closure Devices: Amplatzer® Amulet, Amplatzer® cardiac plug, Implantable hemodynamic monitor, Lariat®, PLAATO, Watchman™ Open a PDF 2020-03-12 Heart & Blood Vessels (Cardiovascular)
7.01.93 Sacroiliac Joint Fusion, IFUSE® Implant System ,SI-FIX, SImmetry® Sacroiliac Joint Fusion System, Silex™ Sacroiliac Joint Fusion System, SI-LOK® Sacroiliac Joint Fixation System Open a PDF 2020-02-24 Bone & Joints (Orthopedic)
7.01.94 Sialendoscopy Open a PDF 2020-05-08 Ear, Nose & Throat (Otorhinolaryngology)
7.01.95 Shoulder Arthroplasty Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.96 Hip Arthroplasty Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
7.01.97 Lumbar Decompression Open a PDF 2020-02-20 Bone & Joints (Orthopedic)
7.01.98 Lumbar Microdiscectomy Open a PDF 2020-09-25 Bone & Joints (Orthopedic)
7.01.99 Drug-Eluting Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery Open a PDF 2020-05-26 Ear, Nose & Throat (Otorhinolaryngology)
7.02.01 Pancreas Transplant (Pancreas Transplant Alone, Pancreas After Kidney Transplant, Simultaneous Pancreas Kidney Transplant) Open a PDF 2020-02-24 Transplants
7.02.02 Allogeneic Hematopoietic Stem Cell Transplantation Open a PDF 2020-03-17 Transplants
7.02.03 Autologous Hematopoietic Stem Cell Transplantation, Autologous Bone Marrow Transplant Open a PDF 2020-03-17 Transplants
7.02.04 Kidney (Renal) Transplantation Open a PDF 2020-04-15 Transplants
7.02.05 Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 2020-04-15 Transplants
7.02.06 Heart and Heart/Lung Transplants Open a PDF 2020-05-07 Transplants
7.02.07 Liver/Hepatic Transplantation Open a PDF 2020-04-20 Transplants
7.02.10 Lung and Lobar Lung Transplant Open a PDF 2020-04-15 Transplants
7.03.01 Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Surgery Open a PDF 2020-02-19 Anesthesiology
7.03.02 Monitored Anesthesia Care (MAC) Open a PDF 2020-06-11 Anesthesiology
7.03.03 Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes Open a PDF 2020-04-15 Drug / Medications
8.01.01 Extracorporeal Photochemotheraphy/Photopheresis Open a PDF 2020-03-04 Skin (Dermatology)
8.01.03 Chelation Therapy (e.g., EDTA, Endrate, Desferal, BAL in oil, Cuprimine, Depen, Zinecard, Exjade, Post-chelator Challeng Urinary Metal Testing, Post-provocation urinary metal testing) Open a PDF 2020-03-04 Blood Disorders (Hematology)
8.01.04 Plasmapheresis, Plasma Exchange and Apheresis, Rheopheresis Open a PDF 2020-03-17 Blood Disorders (Hematology)
8.01.06 Photodynamic Therapy (PDT) for Malignant Disease (Photofrin, Porfimer Sodium) Open a PDF 2020-03-17 Cancer Treatment (Oncology)
8.01.07 Treatment of Tinnitus: Habituation Therapy, Jastreboff Method, Masking, Retraining Therapy Open a PDF 2020-03-17 Ear, Nose & Throat (Otorhinolaryngology)
8.01.10 Prolotherapy (e.g., Sarapin) Open a PDF 2020-03-12 Bone & Joints (Orthopedic)
8.01.11 Photodynamic Therapy (PDT) for Subfoveal Choroidal Neovascularization (CNV) (e.g., Verteporfin, Visudyne) Open a PDF 2020-04-15 Eyes (Ophthalmology)
8.01.12 Physical Therapy (PT) Open a PDF 2020-03-12 Therapy & Rehabilitation
8.01.13 Speech/Language Pathology and Therapy (e.g., Fast ForWord, Lee Silverman Voice Therapy [LSVT-LOUD™],Vocal Cord Dysfunction, Voice Therapy Open a PDF 2020-09-21 Therapy & Rehabilitation
8.01.14 Cardiac Rehabilitation Open a PDF 2020-03-12 Therapy & Rehabilitation
8.01.17 Occupational Therapy (OT), Constraint Induced Movement Therapy (CIMT), Gait Analysis, Sensory Integration Therapy, SIT Open a PDF 2020-07-17 Therapy & Rehabilitation
8.01.18 Nutritional Therapy Open a PDF 2020-03-27 Food (Nutrition)
8.01.19 Cognitive Rehabilitation, Attention Rehabilitation, Sensory Integration Therapy Open a PDF 2020-09-21 Therapy & Rehabilitation
8.01.20 Acupuncture, Auricular Electrostimulation (e.g., E-Pulse, P-Stim™) Open a PDF 2020-05-13 Alternative Medicine
8.01.21 Light and Laser Therapies for Dermatologic Conditions (BCLear Lamp, CureLight Broadband, Excilite Lamp, Levulan®, Kerastick®, Metvix®, Narrow Band Ultraviolet B, Psoralens, PUVA, Ultraviolet Light, UVA, UVB, VTRAC Lamp, XeCL, XTRAC) Open a PDF 2020-03-05 Skin (Dermatology)
8.01.22 Percutaneous Posterior Tibial Nerve Stimulation (PPTNS) Open a PDF 2020-09-25 Nervous Systems (Neurology)
8.01.23 Low Level Laser Therapy (LLLT) Open a PDF 2020-02-24 Skin (Dermatology)
9.01.01 Phototherapeutic Keratoplasty/Keratectomy, PTK Open a PDF 2020-03-06 Eyes (Ophthalmology)
9.01.04 Vision/Eye Therapy: Optometric Phototherapy, Occlusion Therapy, Orthoptics, Pleoptics Open a PDF 2020-02-20 Eyes (Ophthalmology)
9.01.05 Transpupillary Thermotherapy (TTT) Open a PDF 2020-09-25 Eyes (Ophthalmology)
9.01.06 Ophthalmologic Techniques for the Diagnosis of Glaucoma (Scanning Laser Polarimetry and Scanning Laser Ophthalmoscopy): GDx Imaging, Nerve Fiber Analysis, Heidelberg Retina Tomograph, Optomap Open a PDF 2020-04-20 Eyes (Ophthalmology)
9.01.07 Corneal Ultrasound Pachymetry Open a PDF 2020-05-07 Eyes (Ophthalmology)
9.01.08 Refractive Procedures (e.g., Artisan, Astigmatic Keratotomy, Clear Lens Extraction, Photorefractive Keratectomy - PRK, INTACS - Corneal Ring Segments, Intracorneal Inlay, Laser-Assisted Subepithelial Keratomileusis - LASIK, Phakic Intraocular Lens) Open a PDF 2020-03-06 Eyes (Ophthalmology)
9.01.10 Optical Coherence Tomography for Ophthalmological Applications (OCT) Open a PDF 2020-05-07 Eyes (Ophthalmology)
9.01.13 Intrastromal Corneal Ring Segments (ICRS) for Keratoconus (e.g., INTACS) Open a PDF 2020-06-11 Eyes (Ophthalmology)
9.01.14 Intraocular Lens (IOL) Implants (e.g., Accommodating, Aspheric, Crystalens, Dynamic, Monofocal, Multifocal, Pseudoaccommodating) Open a PDF 2020-03-06 Eyes (Ophthalmology)
9.01.15 Keratoprosthesis: AlphaCor™, BIOKOP, Boston type I, Boston type II, Dolhman-Doane, KPro, OOKP Open a PDF 2020-05-07 Eyes (Ophthalmology)
9.01.17 Gas Permeable Scleral Contact Lens (e.g., Boston Ocular Surface Prosthesis, Prosthetic Replacement of the Ocular Surface Ecosystem [PROSE]) Open a PDF 2020-03-20 Eyes (Ophthalmology)
9.01.18 Aqueous Drainage Devices (Stents and Shunts): Ahmed, Aquaflow, Baerveldt, CyPass, Ex-PRESS, Glaucoma Filtration Device, IOP, iStent, Krupin, Molteno, XEN Open a PDF 2020-05-07 Eyes (Ophthalmology)