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Medical Coverage Guidelines
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What's New
Current Guidelines
By Category
Ambulance
Ambulance Services
Durable Medical Equipment
Blood Glucose Monitors and Supplies
Continuous Passive Motion Device
Cooling and Heating Devices Used in the Outpatient Setting (e.g., Ice Man Therapy Unit)
Durable Medical Equipment (DME)
Electric and Electromagnetic Stimulation and Ultrasound for Wound Healing
End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema
External Infusion Pumps (non-insulin)
External Insulin Infusion Pumps and Continuous Glucose Monitors
Functional Neuromuscular Stimulation
Home Cardiorespiratory Monitoring, Infant
Home Pulse Oximetry
Home Spirometry
Hospital Beds and Accessories
Infrared Energy Therapy and Low Level Laser Therapy
Mechanical Stretching Devices
Negative Pressure Wound Therapy (NPWT) Pumps
Neuromuscular Electrical Stimulation (NMES)
Non-Invasive Electrical Bone Growth Stimulators (EBGS)
Noncontact Normothermic Wound Therapy
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
Oxygen
Percutaneous Electrical Nerve Stimulation (PENS)
Pneumatic Compression Devices
Positive Airway Pressure Devices
Positive Pressure Ventilation in Adults
Sacral Nerve Modulation Stimulation
Speech Generating Devices (e.g., Dynavox)
Spinal Cord and Dorsal Root Ganglion Stimulation
Transcutaneous Electric Nerve Stimulation (TENS)
Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease
Ultrasound Osteogenesis Stimulators, Non-invasive
Wheelchairs and Wheelchair Accessories
Medicine
Adoptive Immunotherapy
Advanced Imaging of the Heart-Echocardiography
Allergy Testing and Immunotherapy
Ambulatory Blood Pressure Monitoring (ABPM)
Apheresis, Plasmapheresis and Plasma Exchange
Arterial Ultrasound (Duplex Ultrasounds and Physiologic Testing)
Autonomic Nervous System Testing
Balloon Dilation of the Eustachian Tube
Bioimpedance Devices for Detection and Management of Lymphedema
Cardiac Monitoring Devices
Chelation Therapy
Cognitive Rehabilitation
Diabetic Self-Management Training and Educational Supplies
Diagnostic Coronary Angiography
Elective Percutaneous Coronary Intervention
Electroretinography
Esophageal pH Monitoring
Evoked Potentials, Intraoperative Neurophysiologic Monitoring and Quantitative Electroencephalography (QEEG)
External Counterpulsation (ECP)
Extracorporeal Membrane Oxygenation (ECMO) for Adult Conditions
Extracorporeal Photopheresis (ECP)
Extracorporeal Shock Wave (ESW) Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Extracorporeal Shock Wave Therapy in the Treatment of Peyronie’s Disease
Fecal Microbiota Transplantation
Gastric Electrical Stimulation
Home Prothrombin Time Monitoring
Hyperbaric Oxygen Therapy (Systemic, Topical)
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Ingestible pH and Pressure Capsule
Inhaled Nitric Oxide
Magnetoencephalography/Magnetic Source Imaging
Minimally Invasive Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) and Dysphagia
Nerve Conduction Studies, F-wave Studies, H-reflex Studies
Neuropsychological Testing
Orthopedic Applications of Stem-Cell Therapy
Outpatient Pulmonary Rehabilitation
Pelvic Floor Stimulation as a Treatment of Incontinence
Percutaneous Tibial Nerve Stimulation
Physical Therapy (PT) and Occupational Therapy (OT)
Preventive Services
Psoralens with Ultraviolet A (PUVA) Therapy
Quantitative Sensory Testing
Signal Averaged Electrocardiography (SAECG)
Sleep Testing
Speech Therapy Services
Temporomandibular Joint (TMJ) Dysfunction, Diagnosis and Treatment
Thoracic Electrical Bioimpedance (TEB)
Total Body Plethysmography
Transanal Radiofrequency Therapy as a Treatment of Fecal Incontinence
Transcranial Doppler Studies
Transcranial Magnetic Stimulation
Treatment of Autism Spectrum Disorders
Treatment of Hyperhidrosis
Treatment of Tinnitus
Vestibular Rehabilitation
Wearable and Non-Wearable Cardioverter-Defibrillators
Wireless Capsule Endoscopy
Orthotics and Prosthetics
Cranial Orthosis for Craniosynostoses and Plagiocephaly
Knee Braces
Lower Limb Microprocessor-Controlled Prosthetics
Myoelectric Prosthetic Components for the Upper Limb
Orthotics
Prosthetics
Other
Enteral Formulas
Home Health Care
Hospice Care
Hyperalimentation
Injectable Bulking Agents for Treatment of Fecal Incontinence
Investigational Services
Non-Covered Services
Private Duty Nursing Care in the Home
ProThelial for the Treatment of Oral Mucositis
Technologies for the Evaluation of Malignant Melanoma
Pathology and Laboratory
Analysis of Human DNA as a Technique for Colorectal Cancer Screening
Assays of Genetic Expression in Tumor Tissue - Breast Cancer
Chemoresistance and Chemosensitivity Assays
Drug Testing in Pain Management and Substance Use Disorder Treatment
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Genetic Testing
Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast Ovarian Cancer Syndrome and Other High-Risk Cancers
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Human Papillomavirus (HPV) Testing
Intracellular Micronutrient Analysis
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Laboratory Tests for Heart and Kidney Transplant Rejection
Measurement of Apolipoprotein B (apo B) and Apolipoprotein E (apo E) in Risk Assessment and Management of Cardiovascular Disease
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
Topographic Genotyping
Tumor Genetic Markers
Pharmacy
Encorafenib (Braftovi) Capsule
Abaloparatide (Tymlos)
Abatacept (Orencia) Injection and Infusion
Abemaciclib (Verzenio)
Abiraterone Acetate (Yonsa, Zytiga) Tablet
Acalabrutinib (Calquence) Oral
Adalimumab (Humira)
Ado-trastuzumab emtansine (Kadcylaâ„¢)
Afatinib (Gilotrif TM) Tablets
Agalsidase Beta (Fabrazyme) IV
Alectinib (Alecensa)
Alemtuzumab (Lemtrada) IV
Alpha1-Proteinase Inhibitors (Human)
Altretamine (Hexalen®) Capsules
Anakinra (Kineret) Injection
Apalutamide (Erleada)
Apremilast (Otezla) Tablet
Asfotase alfa (Strensiq)
Asparaginase (Elspar®, Erwinaze™) Injection
Avatrombopag (Doptelet)
Axicabtagene Ciloleucel (Yescarta)
Axitinib (Inlyta®) Tablets
Azacitidine (Vidaza®) Injection
Baricitinib (Olumiant)
Belimumab (Benlysta) Injection
Belinostat (Beleodaq) Injection
Bendamustine HCl Injection
Benralizumab (Fasenra)
Betaine, anhydrous (Cystadane®) Oral Solution
Bevacizumab (Avastin) Injection
Bexarotene (Targretin®) Capsules
Bezlotoxumab (Zinplava) Injection
Binimetinib (Mektovi) Tablet
Blinatumomab (Blincyto TM) IV
Bortezomib (Velcade) Injection
Bosutinib (Bosulifâ„¢) Tablets
Botulinum Toxins
Brentuximab (Adcetris) Injection
Brigatinib (Alunbrig)
Brodalumab (Siliq) Injection
Buprenorphine Hydrochloride (Probuphine) and Buprenorphine (Sublocade)
Burosumab (Crysvita)
Cabazitaxel (Jevtana) Injection
Cabozantinib Capsules and Tablets (Cometriq, Cabometyx)
Canakinumab (Ilaris®) Injection
Cannabidiol (Epidiolex)
Capecitabine (Xeloda®) Tablets
Carboplatin (Paraplatin®) IV
Carfilzomib (Kyprolis) Injection
Cenegermin-bkbj (Oxervate) Ophthalmic Solution
Ceritinib (Zykadia) Capsules
Certolizumab Pegol (Cimzia) Injection
Cholic Acid (Cholbam®) Capsule
Clotting Factors and Coagulant Blood Products
Cobimetinib (Cotellic) Tablet
Contraceptive Drugs
Corticosteroid Intravitreal Implant
Crizotinib (Xalkori) Capsules
Cysteamine Bitartrate (Procysbi TM) Capsules
Dabrafenib (Tafinlar) Capsules
Dacomitinib (Vizimpro)
Dalfampridine (Ampyra) Oral
Daratumumab (Darzalex)
Dasatinib (Sprycel) Tablets
Deflazacort (Emflaza)
Denosumab (Prolia, Xgeva) Injection
Dichlorphenamide (Keveyis)
Dimethyl Fumarate (Tecfidera) Capsule
Dinutuximab (Unituxin TM)
Docetaxel (Taxotere®) IV
Doxorubicin HCl Liposome (Doxil) Injection
Drugs and Biologics without Medical Coverage Guideline
Dupilumab (Dupixent) Injection
Duvelisib (Copiktra) Capsule
Eculizumab (Soliris®) Injection
Edaravone (Radicava)
Elosulfase alfa (Vimizimâ„¢) Injection
Elotuzumab (Empliciti) Injection
Eltrombopag (Promacta®) Tablets
Enasidenib Mesylate (Idhifa) Tablet
Enzalutamide (Xtandi) Capsules
Ergotamine (Ergomar)
Eribulin Mesylate (Halaven®) Injection
Erlotinib (Tarceva) Tablets
Erythropoiesis Stimulating Agents
Etanercept (Enbrel) Injection
Eteplirsen (Exondys 51)
Everolimus (Afinitor, Afinitor Disperz) Tablets
Ferric carboxymaltose (Injectafer®)
Fingolimod (Gilenya) Capsule
Fosnetupitant-Palonosetron (Akynzeo) IV
Fostamatinib (Tavalisse)
Fulvestrant (Faslodex®) IM
Gefitinib (Iressa)
Gemcitabine (Gemzar®)
Glycerol Phenylbutyrate (Ravicti)
Golimumab (Simponi, Simponi Aria) Injection and Infusion
Gonadotropin Releasing Hormone Analogs and Antagonists
Granisetron (Sustol®) injection
Granulocyte Colony Stimulating Factors
Growth Hormone Therapy
Guselkumab (Tremfya) Injection
H.P. Acthar® Gel (repository corticotropin)
Hepatitis C Drug Therapy
Hereditary Angioedema Drug Therapy
Hormone Replacement
Human EGFR Inhibitors (Cetuximab [Erbitux], Panitumumab [Vectibix])
Hydroxyprogesterone Caproate
Ibandronate IV (Boniva®)
Ibrutinib (Imbruvica)
Idelalisib (Zydelig) Oral Tablet
Imatinib Mesylate (Gleevec®) Tablets
Immune Globulin Therapy
Infliximab Products [infliximab (Remicade), infliximab-dyyb (Inflectra), and infliximab-abda (Renflexis)]
Inotersen (Tegsedi)
Intrathecal Drug Therapy for Long-Term Pain Management
Intravenous Enzyme Replacement Therapy for Gaucher Disease
Intravenous Lidocaine for the Management of Chronic Pain
Ipilimumab (Yervoy) Injection
Irinotecan HCl (Camptosar®) IV
Irinotecan Liposome Injection (Onivyde)
Ivacaftor (Kalydeco) Oral
Ivosidenib (Tibsovo) Tablet
Ixazomib (Ninlaro)
Ixekizumab (Taltz) Injection
Lanreotide (Somatuline Depot) Injection
Lapatinib (Tykerb®) Tablets
Lenalidomide (Revlimid)
Lenvatinib (Lenvima)
Levoleucovorin (Fusilev®) IV
Lomitapide (Juxtapidâ„¢) Oral
Lumacaftor Ivacaftor (Orkambi) Capsule
Lusutrombopag (Mulpleta) Tablet
Mecasermin (Increlex®) Injection
Melphalan HCl, Captisol-Enabled (Evomela®) IV Infusion
Mepolizumab (Nucala)
Metreleptin (Myaleptâ„¢) Injection
Midostaurin (Rydapt)
Mifepristone (Korlymâ„¢) Oral
Migalastat (Galafold) Capsule
Mipomersen Sodium (Kynamroâ„¢) Injection
Mitotane (Lysodren®) Tablets
Mogamulizumab-kpkc (Poteligeo) Injection
Multiple Sclerosis Self Injectable Therapy
Nab-Paclitaxel Injection (Abraxane)
Natalizumab (Tysabri) IV
Necitumumab (PortrazzaTM)
Neratinib (Nerlynx)
Nilotinib (Tasigna) Capsules
Nintedanib (Ofev) Oral Capsules
Niraparib (Zejula) Capsule
Nitisinone (Orfadin®) Capsules
Nivolumab (Opdivo)
NK-1 receptor antagonist injectable therapy (Emend, Cinvanti, Varubi)
Nusinersen (Spinraza)
Obeticholic acid (Ocaliva) Tablet
Obinutuzumab (Gazyva) Injection
Ocrelizumab (Ocrevus) Infusion
Octreotide Acetate (Sandostatin LAR Depot) Injection
Olaparib (Lynparza)
Olaratumab (Lartruvo)
Omacetaxine Mepesuccinate (Synriboâ„¢) Injection
Omalizumab (Xolair®)
Ondansetron HCI (Zofran®) IV
Oral Therapy for Gaucher Disease
Osimertinib (TagrissoTM)
Oxaliplatin (Eloxatin®) Injection
Palbociclib (Ibrance TM)
Palivizumab (Synagis®)
Palonosetron Hydrochloride (Aloxi)
Panobinostat (Farydak) Capsule
Parathyroid Hormone (Natpara) Injection
Pasireotide (Signifor® Signifor LAR®) Injection
Patisiran Sodium (Onpattro)
Pazopanib (Votrient) Tablets
PCSK9 Inhibitors
Pegvaliase-pqpz (Palynziq)
Pembrolizumab (Keytruda) Injection
Pemetrexed Disodium (Alimta®) IV
Pertuzumab (Perjetaâ„¢) Injection
Pimavanserin (Nuplazid)
Pirfenidone (Esbriet)
Plerixafor (Mozobil) Injection
Pomalidomide (Pomalyst) Capsule
Ponatinib (Iclusig®) Tablets
Pralatrexate (Folotynâ„¢) IV
Procarbazine (Matulane®) Capsules
Protein C Concentrate, human (Ceprotin) Injection
Pulmonary Hypertension Drug Therapy
Pyridoxine HCl Injection (vitamin B-6)
Pyrimethamine (Daraprim)
Radium Ra 223 (Xofigo®) Injection
Ramucirumab (Cyramza) Injection
Rasburicase (Elitek)
Regorafenib (Stivarga) Tablets
Reslizumab (Cinqair) IV infusion
Ribociclib (Kisqali)
Rilonacept (Arcalyst®) Injection
Rituximab (Rituxan) and Rituximab hyaluronidase (Rituxan Hycela)
Romiplostim Injection (Nplateâ„¢)
Rucaparib (Rubraca)
Ruxolitinib (Jakafi) Tablets
Sacrosidase (Sucraid) Oral Solution
Sapropterin (Kuvan®) Tablets
Sarilumab (Kevzara) Injection
Secukinumab (Cosentyx) Injection
Siltuximab (Sylvantâ„¢) Injection
Sipuleucel-T (Provenge)
Sodium Oxybate (Xyrem®) Oral
Sodium Phenylbutyrate (Buphenyl)
Sonidegib (Odomzo) Capsule
Sorafenib (Nexavar) Tablets
Sunitinib Malate (Sutent) Capsules
Tasimelteon (Hetliozâ„¢) Capsules
Teduglutide (rDNA origin)(Gattex®) Injection
Temozolomide (Temodar®) Capsule and Injection
Temsirolimus (Torisel) Injection
Teriflunomide (Aubagio) Tablets
Teriparatide (Forteo®)
Tesamorelin (Egrifta) Injection
Tetrabenazine (Xenazine) and Deutetrabenazine (Austedo)
Tezacaftor-Ivacaftor (Symdeko)
Thalidomide (Thalomid) Capsules
Thiamine HCl Injection (vitamin B-1)
Tildrakizumab-asmn (Ilumya)
Tiopronin (Thiola®) Tablet
Tisagenlecleucel (Kymriah) Infusion
Tocilizumab (Actemra) Injection and Infusion
Tofacitinib (Xeljanz, Xeljanz XR) Tablets
Tolvaptan (Jynarque)
Tolvaptan (Samscaâ„¢) Oral
Topotecan HCl (Hycamtin®) Injection and Capsule
Trametinib (Mekinist) Tablets
Trastuzumab (Herceptin®) Injection
Tretinoin Oral Capsules
Trifluridine-Tipiracil (Lonsurf) Capsule
Unclassified Codes and Compounded Drug Products
Ustekinumab (Stelara) Injection and Infusion
Valbenazine (Ingrezza)
Vandetanib (Caprelsa) Tablets
Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization
Vedolizumab (Entyvio) Infusion
Vemurafenib (Zelboraf)
Venetoclax (Venclexta) Tablet
Verteporfin (Visudyneâ„¢) Injection
Vinorelbine Tartrate (Navelbine®) IV
Viscosupplementation, Hyaluronan Injections (e.g. Synvisc)
Vitamin B-12 Injections
Voretigene Neparvovec-rzyl (Luxturna) Injection
Vorinostat (Zolinza®) Capsules
Ziv-aflibercept (Zaltrap) IV
Zoledronic Acid IV (Reclast®, Zometa®)
Radiology
Bone Mineral Density Studies
Brachytherapy - Oncologic Applications
Cardiac Nuclear Imaging (Myocardial Perfusion Imaging)
Computed Tomographic (CT) Colonography (Virtual Colonoscopy)
Computed Tomographic Angiography (CTA) Heart
Computed Tomography (CT) Abdomen and Pelvis
Computed Tomography (CT) Extremity (Upper and Lower)
Computed Tomography (CT) Head and Brain
Computed Tomography (CT) Heart
Computed Tomography (CT) of the Neck for Soft Tissue Evaluation
Computed Tomography (CT) Spine (Cervical, Thoracic, Lumbar)
Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial
Computed Tomography (CT) Thorax (Chest)
Computed Tomography Angiography (CTA) Abdomen and Pelvis
Computed Tomography Angiography (CTA) Brain (Head)
Computed Tomography Angiography (CTA) Chest (non coronary)
Computed Tomography Angiography (CTA) Lower Extremity
Computed Tomography Angiography (CTA) Neck
Computed Tomography Angiography (CTA) Upper Extremity
Computed Tomography to Detect Coronary Artery Calcification
Computer Assisted Surgical Navigation
Computerized Dynamic Posturography
Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography
FDG-SPECT
Fractionation and Radiation Therapy
Functional Magnetic Resonance Imaging (fMRI)
Image-Guided Radiation Therapy
Intensity-Modulated Radiation Therapy (IMRT)
Magnetic Resonance Angiography (MRA) Abdomen and Pelvis
Magnetic Resonance Angiography (MRA) Brain (Head)
Magnetic Resonance Angiography (MRA) Chest
Magnetic Resonance Angiography (MRA) Extremity (Upper and Lower)
Magnetic Resonance Angiography (MRA) Neck
Magnetic Resonance Angiography (MRA) Spinal Canal
Magnetic Resonance Cholangiopancreatography (MRCP)
Magnetic Resonance Imaging (MRI) Abdomen and Pelvis
Magnetic Resonance Imaging (MRI) Brain and Head
Magnetic Resonance Imaging (MRI) Cardiac
Magnetic Resonance Imaging (MRI) Chest (Thorax)
Magnetic Resonance Imaging (MRI) Lower Extremity
Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck
Magnetic Resonance Imaging (MRI) Spine
Magnetic Resonance Imaging (MRI) Upper Extremity
Magnetic Resonance Imaging Bone Marrow
Magnetic Resonance Imaging of the Breast
Magnetic Resonance Spectroscopy (MRS)
MRI-Guided High Intensity Focused Ultrasound Ablation
Multiple Gated Acquisition Scan (MUGA)
Noninvasive Fractional Flow Reserve Measurement
Positron Emission Tomography (PET) Cardiac Applications
Positron Emission Tomography (PET) Miscellaneous Applications
Positron Emission Tomography (PET) Oncologic Applications
Proton Beam Therapy
Scintimammography and Gamma Imaging of the Breast
Selective Internal Radiation Therapy
Special Treatment Procedure and Special Physics Consult
Ultrasound in Maternity Care
Whole Body Computed Tomography (CT)
Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition and Other Body Composition Techniques
Surgery
Abortion
Allogeneic Bone Marrow and Stem Cell Transplantation
Allogeneic Pancreas Transplant
Autologous Bone Marrow and Stem Cell Transplantation
Autologous Chondrocyte Implantation (ACI)
Automated Percutaneous Discectomy, Laser Discectomy, Endoscopic Discectomy, or DISC Nucleoplasty as Techniques of Intervertebral Disc Decompression
Balloon Ostial Dilation (Balloon Sinuplasty) and Implantable Devices
Bariatric Surgery
Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid
Blepharoplasty/Brow Surgical Procedures
Bone Morphogenetic Protein (BMP)
Breast Ductoscopy
Bronchial Thermoplasty
Cervical Spine Surgery
Cochlear Implants
Complications of Pregnancy
Computer-Assisted Navigation for Orthopedic Procedures
Cryoablation of Liver Tumors
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Dermatologic, or Prostate Tumors
Deep Brain Stimulation and Responsive Neurostimulation
Dermabrasion, Chemical Peel, Salabrasion, and Acne Surgery
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis
Diaphragmatic Phrenic Nerve Stimulation
Ductal Lavage and Suction Collection Systems
Endoscopic Radiofrequency Ablation or Cryosurgical Ablation for Barrett’s Esophagus
Endovascular Procedures for Intracranial Arterial Disease
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
Endovascular Stent Grafts for Disorders of the Thoracic Aorta
Epidural Injections
Extracranial Carotid Angioplasty Stenting
Facet Arthroplasty
Facet Joint Injections
Femoroacetabular Impingement (FAI) Syndrome Surgery (Open or Arthroscopic)
Frenectomy or Frenotomy for Ankyloglossia (Tongue-Tie)
Gender Reassignment Surgery
Heart and Lung Transplant
Heart Transplant
High Resolution Anoscopy
Hip Arthroplasty
Hip Arthroscopy and Open, Non-Arthroplasty Hip Repair
Implantable Bone-Conduction and Bone-Anchoring Hearing Aids
Implantable Cardioverter Defibrillators
In Utero (Intrauterine) Fetal Surgery
Infertility
Interspinous, Interlaminar Stabilization Distraction, Fixation
Interstitial Laser Therapy
Invasive Electrical Bone Growth Stimulator (EBGS)
Irreversible Electroporation (IRE)
Isolated Small Bowel Transplant
Keratoplasty and Keratectomy
Kidney Transplantation
Knee Arthroplasty
Knee Arthroscopy and Open, Non-Arthroplasty Knee Repair
Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids
Laser Vitreolysis
Left Atrial Appendage Closure
Liver Transplant
Lumbar Spine Surgery
Lung and Lobar Lung Transplant
Lysis of Epidural Adhesions
Manipulation Under Anesthesia
Mastectomy for Gynecomastia
Medical and Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal Passages
Meniscal Allograft Transplantation
Minimally Invasive Fusion Techniques
Mohs Micrographic Surgery
Nerve Block Injections
Neurolysis, Ablation
Occipital Nerve Stimulation
Occlusion of Uterine Arteries Using Transcatheter Embolization
Orthognathic Surgery
Pancreatic Islet Cell Transplantation
Panniculectomy and Abdominoplasty
Partial Left Ventriculectomy and Surgical Ventricular Restoration
Percutaneous Treatment of Fracture Non-unions or Bone Defects with Autologous Bone Marrow with or without Demineralized Bone Matrix (DBM)
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Photocoagulation of Macular Drusen
Platelet-Derived Growth Factors and Autologous Blood-Derived Preparations (Platelet-Rich Plasma)
Plugs for Fistula Repair
Prophylactic Mastectomy
Prostate Saturation Biopsy
Radiofrequency Ablation of Liver Tumors
Radiofrequency Ablation of Solid Tumors Other Than Liver Tumors
Reconstructive Surgery/ Cosmetic Surgery
Reduction Mammoplasty
Sacroiliac Joint Injections
Small Bowel, Liver and Multivisceral Transplant
Stereotactic Body Radiotherapy
Stereotactic Radiosurgery (Intracranial)
Subtalar Arthroereisis
Surgical Treatment of Occipital Neuralgia and Headache
Temporary Prostatic Stent and Prostatic Urethral Lift
Tendon Sheath, Ligament, and Trigger Point Injections
Thermal Intradiscal Procedures (e.g., IDET, IDB, PIRFT)
Thumb Basal Joint Arthroscopy
Total Ankle Replacement
Transanal Endoscopic Microsurgery
Transcatheter Aortic Valve Replacement
Transcatheter Mitral Valve Repair (TMVR)
Transcatheter Pulmonary Valve Implantation
Transmyocardial Revascularization (TMR)
Transvaginal Radiofrequency Bladder Neck Suspension and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Treatments for Varicose Veins Venous Insufficiency
Tumor Treatment Fields Therapy for Glioblastoma
Unicondylar Interpositional Spacer Devices
Vagus Nerve Stimulation
Ventricular Assist Devices and Total Artificial Hearts
Whole Gland Cryoablation of Prostate Cancer
Xenon Chloride Excimer Laser Therapy for Phototherapeutic Treatment of Dermatologic Conditions
Vision and Hearing
Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions
Aqueous Shunts and Stents for Glaucoma
Auditory Integration Training (AIT)
Corneal Pachymetry
Implantation of Intrastromal Corneal Ring Segments
Prosthetic Eyes and Lens Implants
Scanning Computerized Ophthalmic Diagnostic Imaging
Viscocanalostomy and Canaloplasty
Alphabetical
Encorafenib (Braftovi) Capsule
Abaloparatide (Tymlos)
Abatacept (Orencia) Injection and Infusion
Abemaciclib (Verzenio)
Abiraterone Acetate (Yonsa, Zytiga) Tablet
Abortion
Acalabrutinib (Calquence) Oral
Adalimumab (Humira)
Ado-trastuzumab emtansine (Kadcylaâ„¢)
Adoptive Immunotherapy
Advanced Imaging of the Heart-Echocardiography
Afatinib (Gilotrif TM) Tablets
Agalsidase Beta (Fabrazyme) IV
Alectinib (Alecensa)
Alemtuzumab (Lemtrada) IV
Allergy Testing and Immunotherapy
Allogeneic Bone Marrow and Stem Cell Transplantation
Allogeneic Pancreas Transplant
Alpha1-Proteinase Inhibitors (Human)
Altretamine (Hexalen®) Capsules
Ambulance Services
Ambulatory Blood Pressure Monitoring (ABPM)
Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions
Anakinra (Kineret) Injection
Analysis of Human DNA as a Technique for Colorectal Cancer Screening
Apalutamide (Erleada)
Apheresis, Plasmapheresis and Plasma Exchange
Apremilast (Otezla) Tablet
Aqueous Shunts and Stents for Glaucoma
Arterial Ultrasound (Duplex Ultrasounds and Physiologic Testing)
Asfotase alfa (Strensiq)
Asparaginase (Elspar®, Erwinaze™) Injection
Assays of Genetic Expression in Tumor Tissue - Breast Cancer
Auditory Integration Training (AIT)
Autologous Bone Marrow and Stem Cell Transplantation
Autologous Chondrocyte Implantation (ACI)
Automated Percutaneous Discectomy, Laser Discectomy, Endoscopic Discectomy, or DISC Nucleoplasty as Techniques of Intervertebral Disc Decompression
Autonomic Nervous System Testing
Avatrombopag (Doptelet)
Axicabtagene Ciloleucel (Yescarta)
Axitinib (Inlyta®) Tablets
Azacitidine (Vidaza®) Injection
Balloon Dilation of the Eustachian Tube
Balloon Ostial Dilation (Balloon Sinuplasty) and Implantable Devices
Bariatric Surgery
Baricitinib (Olumiant)
Belimumab (Benlysta) Injection
Belinostat (Beleodaq) Injection
Bendamustine HCl Injection
Benralizumab (Fasenra)
Betaine, anhydrous (Cystadane®) Oral Solution
Bevacizumab (Avastin) Injection
Bexarotene (Targretin®) Capsules
Bezlotoxumab (Zinplava) Injection
Binimetinib (Mektovi) Tablet
Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid
Bioimpedance Devices for Detection and Management of Lymphedema
Blepharoplasty/Brow Surgical Procedures
Blinatumomab (Blincyto TM) IV
Blood Glucose Monitors and Supplies
Bone Mineral Density Studies
Bone Morphogenetic Protein (BMP)
Bortezomib (Velcade) Injection
Bosutinib (Bosulifâ„¢) Tablets
Botulinum Toxins
Brachytherapy - Oncologic Applications
Breast Ductoscopy
Brentuximab (Adcetris) Injection
Brigatinib (Alunbrig)
Brodalumab (Siliq) Injection
Bronchial Thermoplasty
Buprenorphine Hydrochloride (Probuphine) and Buprenorphine (Sublocade)
Burosumab (Crysvita)
Cabazitaxel (Jevtana) Injection
Cabozantinib Capsules and Tablets (Cometriq, Cabometyx)
Canakinumab (Ilaris®) Injection
Cannabidiol (Epidiolex)
Capecitabine (Xeloda®) Tablets
Carboplatin (Paraplatin®) IV
Cardiac Monitoring Devices
Cardiac Nuclear Imaging (Myocardial Perfusion Imaging)
Carfilzomib (Kyprolis) Injection
Cenegermin-bkbj (Oxervate) Ophthalmic Solution
Ceritinib (Zykadia) Capsules
Certolizumab Pegol (Cimzia) Injection
Cervical Spine Surgery
Chelation Therapy
Chemoresistance and Chemosensitivity Assays
Cholic Acid (Cholbam®) Capsule
Clotting Factors and Coagulant Blood Products
Cobimetinib (Cotellic) Tablet
Cochlear Implants
Cognitive Rehabilitation
Complications of Pregnancy
Computed Tomographic (CT) Colonography (Virtual Colonoscopy)
Computed Tomographic Angiography (CTA) Heart
Computed Tomography (CT) Abdomen and Pelvis
Computed Tomography (CT) Extremity (Upper and Lower)
Computed Tomography (CT) Head and Brain
Computed Tomography (CT) Heart
Computed Tomography (CT) of the Neck for Soft Tissue Evaluation
Computed Tomography (CT) Spine (Cervical, Thoracic, Lumbar)
Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial
Computed Tomography (CT) Thorax (Chest)
Computed Tomography Angiography (CTA) Abdomen and Pelvis
Computed Tomography Angiography (CTA) Brain (Head)
Computed Tomography Angiography (CTA) Chest (non coronary)
Computed Tomography Angiography (CTA) Lower Extremity
Computed Tomography Angiography (CTA) Neck
Computed Tomography Angiography (CTA) Upper Extremity
Computed Tomography to Detect Coronary Artery Calcification
Computer Assisted Surgical Navigation
Computer-Assisted Navigation for Orthopedic Procedures
Computerized Dynamic Posturography
Continuous Passive Motion Device
Contraceptive Drugs
Cooling and Heating Devices Used in the Outpatient Setting (e.g., Ice Man Therapy Unit)
Corneal Pachymetry
Corticosteroid Intravitreal Implant
Cranial Orthosis for Craniosynostoses and Plagiocephaly
Crizotinib (Xalkori) Capsules
Cryoablation of Liver Tumors
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Dermatologic, or Prostate Tumors
Cysteamine Bitartrate (Procysbi TM) Capsules
Dabrafenib (Tafinlar) Capsules
Dacomitinib (Vizimpro)
Dalfampridine (Ampyra) Oral
Daratumumab (Darzalex)
Dasatinib (Sprycel) Tablets
Deep Brain Stimulation and Responsive Neurostimulation
Deflazacort (Emflaza)
Denosumab (Prolia, Xgeva) Injection
Dermabrasion, Chemical Peel, Salabrasion, and Acne Surgery
Diabetic Self-Management Training and Educational Supplies
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis
Diagnostic Coronary Angiography
Diaphragmatic Phrenic Nerve Stimulation
Dichlorphenamide (Keveyis)
Dimethyl Fumarate (Tecfidera) Capsule
Dinutuximab (Unituxin TM)
Docetaxel (Taxotere®) IV
Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography
Doxorubicin HCl Liposome (Doxil) Injection
Drug Testing in Pain Management and Substance Use Disorder Treatment
Drugs and Biologics without Medical Coverage Guideline
Ductal Lavage and Suction Collection Systems
Dupilumab (Dupixent) Injection
Durable Medical Equipment (DME)
Duvelisib (Copiktra) Capsule
Eculizumab (Soliris®) Injection
Edaravone (Radicava)
Elective Percutaneous Coronary Intervention
Electric and Electromagnetic Stimulation and Ultrasound for Wound Healing
Electroretinography
Elosulfase alfa (Vimizimâ„¢) Injection
Elotuzumab (Empliciti) Injection
Eltrombopag (Promacta®) Tablets
Enasidenib Mesylate (Idhifa) Tablet
End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema
Endoscopic Radiofrequency Ablation or Cryosurgical Ablation for Barrett’s Esophagus
Endovascular Procedures for Intracranial Arterial Disease
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
Endovascular Stent Grafts for Disorders of the Thoracic Aorta
Enteral Formulas
Enzalutamide (Xtandi) Capsules
Epidural Injections
Ergotamine (Ergomar)
Eribulin Mesylate (Halaven®) Injection
Erlotinib (Tarceva) Tablets
Erythropoiesis Stimulating Agents
Esophageal pH Monitoring
Etanercept (Enbrel) Injection
Eteplirsen (Exondys 51)
Everolimus (Afinitor, Afinitor Disperz) Tablets
Evoked Potentials, Intraoperative Neurophysiologic Monitoring and Quantitative Electroencephalography (QEEG)
External Counterpulsation (ECP)
External Infusion Pumps (non-insulin)
External Insulin Infusion Pumps and Continuous Glucose Monitors
Extracorporeal Membrane Oxygenation (ECMO) for Adult Conditions
Extracorporeal Photopheresis (ECP)
Extracorporeal Shock Wave (ESW) Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Extracorporeal Shock Wave Therapy in the Treatment of Peyronie’s Disease
Extracranial Carotid Angioplasty Stenting
Facet Arthroplasty
Facet Joint Injections
FDG-SPECT
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Microbiota Transplantation
Femoroacetabular Impingement (FAI) Syndrome Surgery (Open or Arthroscopic)
Ferric carboxymaltose (Injectafer®)
Fingolimod (Gilenya) Capsule
Fosnetupitant-Palonosetron (Akynzeo) IV
Fostamatinib (Tavalisse)
Fractionation and Radiation Therapy
Frenectomy or Frenotomy for Ankyloglossia (Tongue-Tie)
Fulvestrant (Faslodex®) IM
Functional Magnetic Resonance Imaging (fMRI)
Functional Neuromuscular Stimulation
Gastric Electrical Stimulation
Gefitinib (Iressa)
Gemcitabine (Gemzar®)
Gender Reassignment Surgery
Genetic Testing
Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast Ovarian Cancer Syndrome and Other High-Risk Cancers
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Glycerol Phenylbutyrate (Ravicti)
Golimumab (Simponi, Simponi Aria) Injection and Infusion
Gonadotropin Releasing Hormone Analogs and Antagonists
Granisetron (Sustol®) injection
Granulocyte Colony Stimulating Factors
Growth Hormone Therapy
Guselkumab (Tremfya) Injection
H.P. Acthar® Gel (repository corticotropin)
Heart and Lung Transplant
Heart Transplant
Hepatitis C Drug Therapy
Hereditary Angioedema Drug Therapy
High Resolution Anoscopy
Hip Arthroplasty
Hip Arthroscopy and Open, Non-Arthroplasty Hip Repair
Home Cardiorespiratory Monitoring, Infant
Home Health Care
Home Prothrombin Time Monitoring
Home Pulse Oximetry
Home Spirometry
Hormone Replacement
Hospice Care
Hospital Beds and Accessories
Human EGFR Inhibitors (Cetuximab [Erbitux], Panitumumab [Vectibix])
Human Papillomavirus (HPV) Testing
Hydroxyprogesterone Caproate
Hyperalimentation
Hyperbaric Oxygen Therapy (Systemic, Topical)
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Ibandronate IV (Boniva®)
Ibrutinib (Imbruvica)
Idelalisib (Zydelig) Oral Tablet
Image-Guided Radiation Therapy
Imatinib Mesylate (Gleevec®) Tablets
Immune Globulin Therapy
Implantable Bone-Conduction and Bone-Anchoring Hearing Aids
Implantable Cardioverter Defibrillators
Implantation of Intrastromal Corneal Ring Segments
In Utero (Intrauterine) Fetal Surgery
Infertility
Infliximab Products [infliximab (Remicade), infliximab-dyyb (Inflectra), and infliximab-abda (Renflexis)]
Infrared Energy Therapy and Low Level Laser Therapy
Ingestible pH and Pressure Capsule
Inhaled Nitric Oxide
Injectable Bulking Agents for Treatment of Fecal Incontinence
Inotersen (Tegsedi)
Intensity-Modulated Radiation Therapy (IMRT)
Interspinous, Interlaminar Stabilization Distraction, Fixation
Interstitial Laser Therapy
Intracellular Micronutrient Analysis
Intrathecal Drug Therapy for Long-Term Pain Management
Intravenous Enzyme Replacement Therapy for Gaucher Disease
Intravenous Lidocaine for the Management of Chronic Pain
Invasive Electrical Bone Growth Stimulator (EBGS)
Investigational Services
Ipilimumab (Yervoy) Injection
Irinotecan HCl (Camptosar®) IV
Irinotecan Liposome Injection (Onivyde)
Irreversible Electroporation (IRE)
Isolated Small Bowel Transplant
Ivacaftor (Kalydeco) Oral
Ivosidenib (Tibsovo) Tablet
Ixazomib (Ninlaro)
Ixekizumab (Taltz) Injection
Keratoplasty and Keratectomy
Kidney Transplantation
Knee Arthroplasty
Knee Arthroscopy and Open, Non-Arthroplasty Knee Repair
Knee Braces
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Laboratory Tests for Heart and Kidney Transplant Rejection
Lanreotide (Somatuline Depot) Injection
Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids
Lapatinib (Tykerb®) Tablets
Laser Vitreolysis
Left Atrial Appendage Closure
Lenalidomide (Revlimid)
Lenvatinib (Lenvima)
Levoleucovorin (Fusilev®) IV
Liver Transplant
Lomitapide (Juxtapidâ„¢) Oral
Lower Limb Microprocessor-Controlled Prosthetics
Lumacaftor Ivacaftor (Orkambi) Capsule
Lumbar Spine Surgery
Lung and Lobar Lung Transplant
Lusutrombopag (Mulpleta) Tablet
Lysis of Epidural Adhesions
Magnetic Resonance Angiography (MRA) Abdomen and Pelvis
Magnetic Resonance Angiography (MRA) Brain (Head)
Magnetic Resonance Angiography (MRA) Chest
Magnetic Resonance Angiography (MRA) Extremity (Upper and Lower)
Magnetic Resonance Angiography (MRA) Neck
Magnetic Resonance Angiography (MRA) Spinal Canal
Magnetic Resonance Cholangiopancreatography (MRCP)
Magnetic Resonance Imaging (MRI) Abdomen and Pelvis
Magnetic Resonance Imaging (MRI) Brain and Head
Magnetic Resonance Imaging (MRI) Cardiac
Magnetic Resonance Imaging (MRI) Chest (Thorax)
Magnetic Resonance Imaging (MRI) Lower Extremity
Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck
Magnetic Resonance Imaging (MRI) Spine
Magnetic Resonance Imaging (MRI) Upper Extremity
Magnetic Resonance Imaging Bone Marrow
Magnetic Resonance Imaging of the Breast
Magnetic Resonance Spectroscopy (MRS)
Magnetoencephalography/Magnetic Source Imaging
Manipulation Under Anesthesia
Mastectomy for Gynecomastia
Measurement of Apolipoprotein B (apo B) and Apolipoprotein E (apo E) in Risk Assessment and Management of Cardiovascular Disease
Mecasermin (Increlex®) Injection
Mechanical Stretching Devices
Medical and Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal Passages
Melphalan HCl, Captisol-Enabled (Evomela®) IV Infusion
Meniscal Allograft Transplantation
Mepolizumab (Nucala)
Metreleptin (Myaleptâ„¢) Injection
Midostaurin (Rydapt)
Mifepristone (Korlymâ„¢) Oral
Migalastat (Galafold) Capsule
Minimally Invasive Fusion Techniques
Minimally Invasive Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) and Dysphagia
Mipomersen Sodium (Kynamroâ„¢) Injection
Mitotane (Lysodren®) Tablets
Mogamulizumab-kpkc (Poteligeo) Injection
Mohs Micrographic Surgery
MRI-Guided High Intensity Focused Ultrasound Ablation
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Multiple Gated Acquisition Scan (MUGA)
Multiple Sclerosis Self Injectable Therapy
Myoelectric Prosthetic Components for the Upper Limb
Nab-Paclitaxel Injection (Abraxane)
Natalizumab (Tysabri) IV
Necitumumab (PortrazzaTM)
Negative Pressure Wound Therapy (NPWT) Pumps
Neratinib (Nerlynx)
Nerve Block Injections
Nerve Conduction Studies, F-wave Studies, H-reflex Studies
Neurolysis, Ablation
Neuromuscular Electrical Stimulation (NMES)
Neuropsychological Testing
Nilotinib (Tasigna) Capsules
Nintedanib (Ofev) Oral Capsules
Niraparib (Zejula) Capsule
Nitisinone (Orfadin®) Capsules
Nivolumab (Opdivo)
NK-1 receptor antagonist injectable therapy (Emend, Cinvanti, Varubi)
Non-Covered Services
Non-Invasive Electrical Bone Growth Stimulators (EBGS)
Noncontact Normothermic Wound Therapy
Noninvasive Fractional Flow Reserve Measurement
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
Nusinersen (Spinraza)
Obeticholic acid (Ocaliva) Tablet
Obinutuzumab (Gazyva) Injection
Occipital Nerve Stimulation
Occlusion of Uterine Arteries Using Transcatheter Embolization
Ocrelizumab (Ocrevus) Infusion
Octreotide Acetate (Sandostatin LAR Depot) Injection
Olaparib (Lynparza)
Olaratumab (Lartruvo)
Omacetaxine Mepesuccinate (Synriboâ„¢) Injection
Omalizumab (Xolair®)
Ondansetron HCI (Zofran®) IV
Oral Therapy for Gaucher Disease
Orthognathic Surgery
Orthopedic Applications of Stem-Cell Therapy
Orthotics
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
Osimertinib (TagrissoTM)
Outpatient Pulmonary Rehabilitation
Oxaliplatin (Eloxatin®) Injection
Oxygen
Palbociclib (Ibrance TM)
Palivizumab (Synagis®)
Palonosetron Hydrochloride (Aloxi)
Pancreatic Islet Cell Transplantation
Panniculectomy and Abdominoplasty
Panobinostat (Farydak) Capsule
Parathyroid Hormone (Natpara) Injection
Partial Left Ventriculectomy and Surgical Ventricular Restoration
Pasireotide (Signifor® Signifor LAR®) Injection
Patisiran Sodium (Onpattro)
Pazopanib (Votrient) Tablets
PCSK9 Inhibitors
Pegvaliase-pqpz (Palynziq)
Pelvic Floor Stimulation as a Treatment of Incontinence
Pembrolizumab (Keytruda) Injection
Pemetrexed Disodium (Alimta®) IV
Percutaneous Electrical Nerve Stimulation (PENS)
Percutaneous Tibial Nerve Stimulation
Percutaneous Treatment of Fracture Non-unions or Bone Defects with Autologous Bone Marrow with or without Demineralized Bone Matrix (DBM)
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Pertuzumab (Perjetaâ„¢) Injection
Photocoagulation of Macular Drusen
Physical Therapy (PT) and Occupational Therapy (OT)
Pimavanserin (Nuplazid)
Pirfenidone (Esbriet)
Platelet-Derived Growth Factors and Autologous Blood-Derived Preparations (Platelet-Rich Plasma)
Plerixafor (Mozobil) Injection
Plugs for Fistula Repair
Pneumatic Compression Devices
Pomalidomide (Pomalyst) Capsule
Ponatinib (Iclusig®) Tablets
Positive Airway Pressure Devices
Positive Pressure Ventilation in Adults
Positron Emission Tomography (PET) Cardiac Applications
Positron Emission Tomography (PET) Miscellaneous Applications
Positron Emission Tomography (PET) Oncologic Applications
Pralatrexate (Folotynâ„¢) IV
Preventive Services
Private Duty Nursing Care in the Home
Procarbazine (Matulane®) Capsules
Prophylactic Mastectomy
Prostate Saturation Biopsy
Prosthetic Eyes and Lens Implants
Prosthetics
Protein C Concentrate, human (Ceprotin) Injection
ProThelial for the Treatment of Oral Mucositis
Proton Beam Therapy
Psoralens with Ultraviolet A (PUVA) Therapy
Pulmonary Hypertension Drug Therapy
Pyridoxine HCl Injection (vitamin B-6)
Pyrimethamine (Daraprim)
Quantitative Sensory Testing
Radiofrequency Ablation of Liver Tumors
Radiofrequency Ablation of Solid Tumors Other Than Liver Tumors
Radium Ra 223 (Xofigo®) Injection
Ramucirumab (Cyramza) Injection
Rasburicase (Elitek)
Reconstructive Surgery/ Cosmetic Surgery
Reduction Mammoplasty
Regorafenib (Stivarga) Tablets
Reslizumab (Cinqair) IV infusion
Ribociclib (Kisqali)
Rilonacept (Arcalyst®) Injection
Rituximab (Rituxan) and Rituximab hyaluronidase (Rituxan Hycela)
Romiplostim Injection (Nplateâ„¢)
Rucaparib (Rubraca)
Ruxolitinib (Jakafi) Tablets
Sacral Nerve Modulation Stimulation
Sacroiliac Joint Injections
Sacrosidase (Sucraid) Oral Solution
Sapropterin (Kuvan®) Tablets
Sarilumab (Kevzara) Injection
Scanning Computerized Ophthalmic Diagnostic Imaging
Scintimammography and Gamma Imaging of the Breast
Secukinumab (Cosentyx) Injection
Selective Internal Radiation Therapy
Signal Averaged Electrocardiography (SAECG)
Siltuximab (Sylvantâ„¢) Injection
Sipuleucel-T (Provenge)
Sleep Testing
Small Bowel, Liver and Multivisceral Transplant
Sodium Oxybate (Xyrem®) Oral
Sodium Phenylbutyrate (Buphenyl)
Sonidegib (Odomzo) Capsule
Sorafenib (Nexavar) Tablets
Special Treatment Procedure and Special Physics Consult
Speech Generating Devices (e.g., Dynavox)
Speech Therapy Services
Spinal Cord and Dorsal Root Ganglion Stimulation
Stereotactic Body Radiotherapy
Stereotactic Radiosurgery (Intracranial)
Subtalar Arthroereisis
Sunitinib Malate (Sutent) Capsules
Surgical Treatment of Occipital Neuralgia and Headache
Tasimelteon (Hetliozâ„¢) Capsules
Technologies for the Evaluation of Malignant Melanoma
Teduglutide (rDNA origin)(Gattex®) Injection
Temozolomide (Temodar®) Capsule and Injection
Temporary Prostatic Stent and Prostatic Urethral Lift
Temporomandibular Joint (TMJ) Dysfunction, Diagnosis and Treatment
Temsirolimus (Torisel) Injection
Tendon Sheath, Ligament, and Trigger Point Injections
Teriflunomide (Aubagio) Tablets
Teriparatide (Forteo®)
Tesamorelin (Egrifta) Injection
Tetrabenazine (Xenazine) and Deutetrabenazine (Austedo)
Tezacaftor-Ivacaftor (Symdeko)
Thalidomide (Thalomid) Capsules
Thermal Intradiscal Procedures (e.g., IDET, IDB, PIRFT)
Thiamine HCl Injection (vitamin B-1)
Thoracic Electrical Bioimpedance (TEB)
Thumb Basal Joint Arthroscopy
Tildrakizumab-asmn (Ilumya)
Tiopronin (Thiola®) Tablet
Tisagenlecleucel (Kymriah) Infusion
Tocilizumab (Actemra) Injection and Infusion
Tofacitinib (Xeljanz, Xeljanz XR) Tablets
Tolvaptan (Jynarque)
Tolvaptan (Samscaâ„¢) Oral
Topographic Genotyping
Topotecan HCl (Hycamtin®) Injection and Capsule
Total Ankle Replacement
Total Body Plethysmography
Trametinib (Mekinist) Tablets
Transanal Endoscopic Microsurgery
Transanal Radiofrequency Therapy as a Treatment of Fecal Incontinence
Transcatheter Aortic Valve Replacement
Transcatheter Mitral Valve Repair (TMVR)
Transcatheter Pulmonary Valve Implantation
Transcranial Doppler Studies
Transcranial Magnetic Stimulation
Transcutaneous Electric Nerve Stimulation (TENS)
Transmyocardial Revascularization (TMR)
Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease
Transvaginal Radiofrequency Bladder Neck Suspension and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Trastuzumab (Herceptin®) Injection
Treatment of Autism Spectrum Disorders
Treatment of Hyperhidrosis
Treatment of Tinnitus
Treatments for Varicose Veins Venous Insufficiency
Tretinoin Oral Capsules
Trifluridine-Tipiracil (Lonsurf) Capsule
Tumor Genetic Markers
Tumor Treatment Fields Therapy for Glioblastoma
Ultrasound in Maternity Care
Ultrasound Osteogenesis Stimulators, Non-invasive
Unclassified Codes and Compounded Drug Products
Unicondylar Interpositional Spacer Devices
Ustekinumab (Stelara) Injection and Infusion
Vagus Nerve Stimulation
Valbenazine (Ingrezza)
Vandetanib (Caprelsa) Tablets
Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization
Vedolizumab (Entyvio) Infusion
Vemurafenib (Zelboraf)
Venetoclax (Venclexta) Tablet
Ventricular Assist Devices and Total Artificial Hearts
Verteporfin (Visudyneâ„¢) Injection
Vestibular Rehabilitation
Vinorelbine Tartrate (Navelbine®) IV
Viscocanalostomy and Canaloplasty
Viscosupplementation, Hyaluronan Injections (e.g. Synvisc)
Vitamin B-12 Injections
Voretigene Neparvovec-rzyl (Luxturna) Injection
Vorinostat (Zolinza®) Capsules
Wearable and Non-Wearable Cardioverter-Defibrillators
Wheelchairs and Wheelchair Accessories
Whole Body Computed Tomography (CT)
Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition and Other Body Composition Techniques
Whole Gland Cryoablation of Prostate Cancer
Wireless Capsule Endoscopy
Xenon Chloride Excimer Laser Therapy for Phototherapeutic Treatment of Dermatologic Conditions
Ziv-aflibercept (Zaltrap) IV
Zoledronic Acid IV (Reclast®, Zometa®)
Certificate of Medical Necessity
Medical Records Fax Coversheet
Allergy Testing CMN
Allogeneic Bone Marrow and Stem Cell Transplant CMN
Allogeneic Pancreas Transplant CMN
Ambulance Services CMN
Bariatric Surgery CMN
Blepharoplasty and Brow Surgical Procedures CMN
Blood Glucose Monitors and Supplies CMN
ChelationTherapy CMN
Chiropractic Services Medicare CMN
Genetic Testing for Hereditary Breast or Ovarian Cancer CMN
Heart and Lung Transplant CMN
Heart Transplant CMN
Hyperalimentation CMN
Infertility CMN
Kidney Transplantation CMN
Liver Transplant CMN
Lung and Lobar Lung Transplant CMN
Manipulation under Anesthesia CMN
Mastectomy for Gynecomastia CMN
Mechanical Stretching Devices CMN
Nerve Block Injections CMN
Orthotics CMN
Outpatient Pulmonary Rehabilitation Services CMN
Pancreatic Islet Cell Transplantation CMN
Reduction Mammoplasty CMN
Scanning Computerized Ophthalmic Diagnostic Imaging CMN
Septoplasty CMN
Small Bowel Transplant CMN
Small Bowel, Liver, and Multivisceral Transplant CMN
Speech Therapy CMN
Speech Therapy in the Home CMN
Ultrasounds in Maternity Care CMN
Wheelchairs and Wheelchair Components CMN
Wireless Capsule Endoscopy CMN
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