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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, Electromagnetic Stimulation, Ultrasound Wound Healing
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 for Treatment of Joint Stiffness and Contractures
Negative Pressure Wound Therapy (NPWT)
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
Sacral Nerve Neuromodulation/Stimulation
Speech Generating Devices
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
Diagnosis and Treatment of Temporomandibular Joint Disorder
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
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
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 as a Technique to Determine Prognosis in Patients with Breast Cancer
Chemoresistance and Chemosensitivity Assays
Drug Testing in Pain Management and Substance Use Disorder Treatment
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
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
Intracellular Micronutrient Analysis
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Laboratory Tests Post Transplant and for Heart Failure
Measurement of Apolipoprotein B (apo B) and Apolipoprotein E (apo E) in Risk Assessment and Management of Cardiovascular Disease
Molecular Testing for the Management of Pancreatic Cysts, Barrett Esophagus, and Solid Pancreatic Lesions
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
Tumor Genetic Markers
Pharmacy
Omadacycline (Nuzyra) Tablet
Abaloparatide (Tymlos)
Abatacept (Orencia) Injection and Infusion
Abemaciclib (Verzenio)
Abiraterone Acetate (Yonsa, Zytiga) Tablet
Acalabrutinib (Calquence) Oral
Adalimumab (Humira) Injection
Ado-trastuzumab emtansine (Kadcyla)
Afatinib (Gilotrif) Tablets
Agalsidase Beta (Fabrazyme) IV
Alectinib (Alecensa)
Alemtuzumab (Lemtrada) IV
Alpelisib (Piqray) Tablet
Alpha1-Proteinase Inhibitors (Human)
Amifampridine Phosphate (Firdapse, Ruzurgi)
Anakinra (Kineret) Injection
Apalutamide (Erleada) Tablet
Apremilast (Otezla) Tablet
Asfotase alfa (Strensiq)
Asparaginase (Elspar, Erwinaze) Injection
Avapritinib (Ayvakit)
Avatrombopag (Doptelet)
Axicabtagene Ciloleucel (Yescarta)
Axitinib (Inlyta) Tablets
Azacitidine (Vidaza) Injection
Baricitinib (Olumiant) Tablet
Belantamab Mafodotin-blmf (Blenrep) IV Infusion
Belimumab (Benlysta) Injection
Belinostat (Beleodaq) Injection
Bendamustine HCl Injection
Benralizumab (Fasenra)
Betaine, anhydrous (Cystadane) Oral Solution
Bevacizumab Products
Bexarotene (Targretin) Capsules
Bezlotoxumab (Zinplava) Injection
Binimetinib (Mektovi) Tablet
Blinatumomab (Blincyto) IV
Bortezomib (Velcade) Injection
Bosutinib (Bosulif) Tablets
Botulinum Toxins
Brentuximab (Adcetris) Injection
Brexanolone (Zulresso) IV Infusion
Brexucabtagene Autoleucel (Tecartus) Infusion
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
Caplacizumab-yhdp (Cablivi)
Carboplatin (Paraplatin®) IV
Carfilzomib (Kyprolis) Injection
Cenegermin-bkbj (Oxervate)
Ceritinib (Zykadia) Capsules
Certolizumab Pegol (Cimzia) Injection
Cholic Acid (Cholbam®) Capsule
Cladribine (Mavenclad) tablets
Clotting Factors and Coagulant Blood Products
Cobimetinib (Cotellic) Tablet
Contraceptive Drugs
Corticosteroid Intravitreal Implant
Crizanlizumab-tmca (Adakveo)
Crizotinib (Xalkori) Capsules
Cysteamine products (Procysbi, Cystadrops, Cystaran)
Dabrafenib (Tafinlar) Capsules
Dacomitinib (Vizimpro)
Daratumumab (Darzalex)
Darolutamide (Nubeqa)
Dasatinib (Sprycel) Tablets
Deflazacort (Emflaza)
Denosumab (Prolia, Xgeva) Injection
Dichlorphenamide (Keveyis)
Dimethyl Fumarate (Tecfidera), Diroximel fumarate (Vumerity), Monomethyl fumarate (Bafiertam) Capsule
Dinutuximab (Unituxin TM)
Docetaxel (Taxotere) IV
Doxorubicin HCl Liposome (Doxil) Injection
Droxidopa (Northera)
Drugs and Biologics without Medical Coverage Guideline
Dupilumab (Dupixent) Injection
Duvelisib (Copiktra)
Eculizumab (Soliris) Injection
Edaravone (Radicava)
Elapegademase-lvlr (Revcovi) Injection
Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)
Elosulfase alfa (Vimizimâ„¢) Injection
Elotuzumab (Empliciti) Injection
Eltrombopag (Promacta) Tablets
Emapalumab-lzsg (Gamifant) IV
Enasidenib Mesylate (Idhifa) Tablet
Encorafenib (Braftovi) Capsule
Enfortumab Vedotin-ejfv (Padcev) IV
Entrectinib (Rozlytrek)
Enzalutamide (Xtandi) Capsules
Eptinezumab-jjmr (Vyepti)
Erdafitinib (Balversa)
Ergotamine (Ergomar)
Eribulin Mesylate (Halaven) Injection
Erlotinib (Tarceva) Tablets
Erythropoiesis Stimulating Agents
Esketamine (Spravato) Nasal Spray
Etanercept (Enbrel) Injection
Eteplirsen (Exondys 51)
Everolimus (Afinitor, Afinitor Disperz) Tablets
Fam-Trastuzumab Deruxtecan-nxki (Enhertu)
Fedratinib (Inrebic) capsules
Fingolimod (Gilenya) Capsule
Fosnetupitant-Palonosetron (Akynzeo) IV
Fostamatinib (Tavalisse)
Fulvestrant (Faslodex®) IM
Gefitinib (Iressa)
Gemcitabine (Gemzar)
Gilteritinib (Xospata)
Givosiran (Givlaari) SQ
Glasdegib (Daurismo)
Glycerol Phenylbutyrate (Ravicti)
Golimumab (Simponi, Simponi Aria) Injection and Infusion
Golodirsen (Vyondys 53)
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) Injection
Ibrutinib (Imbruvica)
Idelalisib (Zydelig) Oral Tablet
Imatinib Mesylate (Gleevec) Tablets
Immune Globulin Therapy
Inebilizumab (Uplizna) Injection
Infliximab Products
Inhaled Nitric Oxide
Injectable Iron Therapy
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)
Isatuximab-irfc (Sarclisa) Infusion
Ivacaftor (Kalydeco) Oral
Ivosidenib (Tibsovo)
Ixazomib (Ninlaro) Capsule
Ixekizumab (Taltz) Injection
Lanreotide (Somatuline Depot) Injection
Lapatinib (Tykerb) Tablets
Larotrectinib (Vitrakvi)
Lenalidomide (Revlimid)
Lenvatinib (Lenvima)
Levoleucovorin (Fusilev, Khapzory)
Lisocabtagene Maraleucel (Breyanzi) Infusion
Lomitapide (Juxtapidâ„¢) Oral
Lorlatinib (Lorbrena)
Lumacaftor Ivacaftor (Orkambi) Capsule
Luspatercept-aamt (Reblozyl)
Lusutrombopag (Mulpleta) Tablet
Mecasermin (Increlex®) Injection
Melphalan HCl, Captisol-Enabled (Evomela) IV Infusion
Mepolizumab (Nucala)
Metreleptin (Myaleptâ„¢) Injection
Midostaurin (Rydapt)
Mifepristone (Korlym) Oral
Migalastat (Galafold)
Mipomersen Sodium (Kynamro) Injection
Mogamulizumab-kpkc (Poteligeo) Injection
Multiple Sclerosis Self Injectable Therapy
Nab-Paclitaxel Injection (Abraxane)
Natalizumab (Tysabri) IV
Necitumumab (Portrazza)
Neratinib (Nerlynx)
Nilotinib (Tasigna) Capsules
Nintedanib (Ofev) Oral
Niraparib (Zejula) Capsule
Nitisinone (Orfadin®) Capsules
Nivolumab (Opdivo)
NK-1 receptor antagonist injectable therapy (Emend, Cinvanti)
Nusinersen (Spinraza)
Obeticholic Acid (Ocaliva) Tablet
Obinutuzumab (Gazyva) Injection
Ocrelizumab (Ocrevus) Infusion
Octreotide Acetate (Sandostatin LAR Depot, Bynfezia Pen, Mycapssa Capsule)
Olaparib (Lynparza)
Olaratumab (Lartruvo)
Omacetaxine Mepesuccinate (Synriboâ„¢) Injection
Omalizumab (Xolair)
Onasemnogene abeparvovec (Zolgensma)
Ondansetron HCI (Zofran®) IV
Oral Oncology Medications
Oral Therapy for Gaucher Disease
Osilodrostat (Isturisa)
Osimertinib (Tagrisso)
Oxaliplatin (Eloxatin®) Injection
Ozanimod (Zeposia) Capsules
Palbociclib (Ibrance)
Palivizumab (Synagis)
Palonosetron Hydrochloride (Aloxi)
Panobinostat (Farydak) Capsule
Parathyroid Hormone (Natpara) Injection
Pasireotide (Signifor Signifor LAR) Injection
Patisiran Sodium (Onpattro)
Pazopanib (Votrient) Tablets
Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)
Pegloticase (Krystexxa) Infusion
Pegvaliase-pqpz (Palynziq)
Pembrolizumab (Keytruda) Injection
Pemetrexed Disodium (Alimta, Pemfexy) IV
Pertuzumab (Perjeta) Injection
Pertuzumab, Trastuzumab, Hyaluronidase-zzxf (Phesgo)
Pexidartinib (Turalio)
Pimavanserin (Nuplazid)
Pirfenidone (Esbriet)
Pitolisant (Wakix)
Plerixafor (Mozobil) Injection
Polatuzumab vedotin-piiq (Polivy)
Pomalidomide (Pomalyst) Capsule
Ponatinib (Iclusig) Tablets
Pralatrexate (Folotyn) IV
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)
Ravulizumab (Ultomiris) IV
Regorafenib (Stivarga) Tablets
Remdesivir (Veklury)
Reslizumab (Cinqair) IV infusion
Ribociclib (Kisqali)
Rilonacept (Arcalyst®) Injection
Riluzole (Tiglutik)
Risankizumab-rzaa (Skyrizi) Injection
Risdiplam (Evrysdi)
Rituximab (Rituxan) and Rituximab hyaluronidase (Rituxan Hycela)
Romiplostim Injection (Nplate)
Romosozumab-aqqg (Evenity)
Rucaparib (Rubraca)
Ruxolitinib (Jakafi ) Oral
Sacituzumab Govitecan-hziy (Trodelvy)
Sacrosidase (Sucraid) Oral Solution
Sapropterin (Kuvan®) Tablets
Sarilumab (Kevzara) Injection
SARS-CoV-2 Monoclonal Antibodies
Satralizumab (Enspryng)
Secukinumab (Cosentyx) Injection
Selinexor (Xpovio) Tablet
Siltuximab (Sylvantâ„¢) Injection
Siponimod (Mayzent) tablets
Sipuleucel-T (Provenge)
Site of Care Guideline for Select Specialty Medications
Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybates (Xywav) Oral Solutions
Sodium Phenylbutyrate (Buphenyl)
Sonidegib (Odomzo) Capsule
Sorafenib (Nexavar) Tablets
Sunitinib Malate (Sutent) Capsules
Tafamidis (Vyndamax, Vyndaqel) Oral
Tafasitamab-cxix (Monjuvi) IV Infusion
Talazoparib (Talzenna)
Tasimelteon (Hetlioz) Capsules
Teduglutide (rDNA origin)(Gattex) Injection
Temozolomide (Temodar) Capsule and Injection
Temsirolimus (Torisel) Injection
Teprotumumab (Tepezza) Infusion
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, Thiola EC) Tablet
Tisagenlecleucel (Kymriah) Infusion
Tocilizumab (Actemra) Injection and Infusion
Tofacitinib (Xeljanz, Xeljanz XR) Tablets
Tolvaptan (Jynarque) Tablet
Tolvaptan (Samscaâ„¢) Oral
Topotecan HCl (Hycamtin) Injection and Capsule
Trametinib (Mekinist) Tablets
Trastuzumab (Herceptin) Injection
Tretinoin Oral Capsules
Trifluridine-Tipiracil (Lonsurf) Capsule
Triheptanoin (Dojolvi) Oral Liquid
Unclassified Codes and Compounded Drug Products
Upadacitinib (Rinvoq)
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
Viltolarsen (Viltepso)
Vinorelbine Tartrate (Navelbine®) IV
Viscosupplementation, Hyaluronan Injections (e.g. Synvisc®)
Vismodegib (Erivedge) Capsules
Vitamin B-12 Injections
Voretigene Neparvovec-rzyl (Luxturna) Injection
Vorinostat (Zolinza) Capsules
Voxelotor (Oxbryta)
Zanubrutinib (Brukinsa)
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 - Guided High Intensity Focused Ultrasound Ablation
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) Chest (Thorax)
Magnetic Resonance Imaging (MRI) Chest and Cardiac
Magnetic Resonance Imaging (MRI) Lower Extremity
Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck
Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar)
Magnetic Resonance Imaging (MRI) Upper Extremity
Magnetic Resonance Imaging Bone Marrow
Magnetic Resonance Imaging of the Breast
Magnetic Resonance Spectroscopy (MRS)
Multiple Gated Acquisition Scan (MUGA)
Noninvasive Fractional Flow Reserve Measurement
PET Oncologic Applications
Positron Emission Tomography (PET Scans) Cardiac Applications
Positron Emission Tomography (PET) Miscellaneous 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 Hematopoietic Cell Transplantation
Allogeneic Pancreas Transplant
Autologous Chondrocyte Implantation (ACI)
Autologous Hematopoietic Cell Transplantation
Automated Percutaneous Discectomy, Laser Discectomy, Percutaneous Endoscopic Discectomy, and DISC Nucleoplasty
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
Endothelial Keratoplasty and Corneal Collagen Cross-Linking
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) and Extracranial Vertebral Artery Disease
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
Endovascular Stent Grafts for Disorders of the Thoracic Aorta
Epidural Injections
Extracranial Carotid Angioplasty Stenting
Facet Joint Injections
Frenectomy or Frenotomy for Ankyloglossia (Tongue-Tie) in Newborns, Children, & Adolescents
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, Bone-Anchoring Hearing Aids
Implantable Cardioverter Defibrillators
In Utero (Intrauterine) Fetal Surgery
Infertility
Interspinous and Interlaminar Stabilization/Distraction (Spacers) and Fixation (Fusion) Devices
Interstitial Laser Therapy for Breast Tumors
Invasive Electrical Bone Growth Stimulator (EBGS)
Irreversible Electroporation (IRE)
Islet Cell Transplantation
Isolated Small Bowel Transplant
Kidney Transplant
Knee Arthroplasty
Knee Arthroscopy and Open, Non-Arthroplasty Knee Repair
Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids
Laser Vitreolysis
Liver Transplant and Combined Liver-Kidney Transplant
Lumbar Spine Surgery
Lung and Lobar Lung Transplant
Lysis of Epidural Adhesions
Manipulation Under Anesthesia
Mastectomy for Gynecomastia
Medical & Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal Passages
Minimally Invasive Fusion Techniques
Mohs Micrographic Surgery
Nerve Block Injections
Neurolysis, Ablation
Occipital Nerve Stimulation
Occlusion of Uterine Arteries Using Transcatheter Embolization
Orthognathic Surgery
Panniculectomy and Abdominoplasty
Partial Left Ventriculectomy and Surgical Ventricular Restoration
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Photocoagulation of Macular Drusen
Platelet-Derived Growth Factors and 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 Mammaplasty
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
Thumb Basal Joint Arthroscopy
Total Ankle Replacement
Total Facet Arthroplasty
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
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 and Sensory Integration Training Therapy (AIT)
Corneal Pachymetry
Implantation of Intrastromal Corneal Ring Segments
Prosthetic Eyes and Lens Implants
Scanning Computerized Ophthalmic Diagnostic Imaging
Viscocanalostomy and Canaloplasty
Alphabetical
Omadacycline (Nuzyra) Tablet
Abaloparatide (Tymlos)
Abatacept (Orencia) Injection and Infusion
Abemaciclib (Verzenio)
Abiraterone Acetate (Yonsa, Zytiga) Tablet
Abortion
Acalabrutinib (Calquence) Oral
Adalimumab (Humira) Injection
Ado-trastuzumab emtansine (Kadcyla)
Adoptive Immunotherapy
Advanced Imaging of the Heart-Echocardiography
Afatinib (Gilotrif) Tablets
Agalsidase Beta (Fabrazyme) IV
Alectinib (Alecensa)
Alemtuzumab (Lemtrada) IV
Allergy Testing and Immunotherapy
Allogeneic Hematopoietic Cell Transplantation
Allogeneic Pancreas Transplant
Alpelisib (Piqray) Tablet
Alpha1-Proteinase Inhibitors (Human)
Ambulance Services
Ambulatory Blood Pressure Monitoring (ABPM)
Amifampridine Phosphate (Firdapse, Ruzurgi)
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) Tablet
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 as a Technique to Determine Prognosis in Patients with Breast Cancer
Auditory and Sensory Integration Training Therapy (AIT)
Autologous Chondrocyte Implantation (ACI)
Autologous Hematopoietic Cell Transplantation
Automated Percutaneous Discectomy, Laser Discectomy, Percutaneous Endoscopic Discectomy, and DISC Nucleoplasty
Autonomic Nervous System Testing
Avapritinib (Ayvakit)
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) Tablet
Belantamab Mafodotin-blmf (Blenrep) IV Infusion
Belimumab (Benlysta) Injection
Belinostat (Beleodaq) Injection
Bendamustine HCl Injection
Benralizumab (Fasenra)
Betaine, anhydrous (Cystadane) Oral Solution
Bevacizumab Products
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) IV
Blood Glucose Monitors and Supplies
Bone Mineral Density Studies
Bone Morphogenetic Protein (BMP)
Bortezomib (Velcade) Injection
Bosutinib (Bosulif) Tablets
Botulinum Toxins
Brachytherapy - Oncologic Applications
Breast Ductoscopy
Brentuximab (Adcetris) Injection
Brexanolone (Zulresso) IV Infusion
Brexucabtagene Autoleucel (Tecartus) Infusion
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
Caplacizumab-yhdp (Cablivi)
Carboplatin (Paraplatin®) IV
Cardiac Monitoring Devices
Cardiac Nuclear Imaging (Myocardial Perfusion Imaging)
Carfilzomib (Kyprolis) Injection
Cenegermin-bkbj (Oxervate)
Ceritinib (Zykadia) Capsules
Certolizumab Pegol (Cimzia) Injection
Cervical Spine Surgery
Chelation Therapy
Chemoresistance and Chemosensitivity Assays
Cholic Acid (Cholbam®) Capsule
Cladribine (Mavenclad) tablets
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
Crizanlizumab-tmca (Adakveo)
Crizotinib (Xalkori) Capsules
Cryoablation of Liver Tumors
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Dermatologic, or Prostate Tumors
Cysteamine products (Procysbi, Cystadrops, Cystaran)
Dabrafenib (Tafinlar) Capsules
Dacomitinib (Vizimpro)
Daratumumab (Darzalex)
Darolutamide (Nubeqa)
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
Diagnosis and Treatment of Temporomandibular Joint Disorder
Diagnostic Coronary Angiography
Diaphragmatic Phrenic Nerve Stimulation
Dichlorphenamide (Keveyis)
Dimethyl Fumarate (Tecfidera), Diroximel fumarate (Vumerity), Monomethyl fumarate (Bafiertam) Capsule
Dinutuximab (Unituxin TM)
Docetaxel (Taxotere) IV
Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography
Doxorubicin HCl Liposome (Doxil) Injection
Droxidopa (Northera)
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)
Eculizumab (Soliris) Injection
Edaravone (Radicava)
Elapegademase-lvlr (Revcovi) Injection
Elective Percutaneous Coronary Intervention
Electric, Electromagnetic Stimulation, Ultrasound Wound Healing
Electroretinography
Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)
Elosulfase alfa (Vimizimâ„¢) Injection
Elotuzumab (Empliciti) Injection
Eltrombopag (Promacta) Tablets
Emapalumab-lzsg (Gamifant) IV
Enasidenib Mesylate (Idhifa) Tablet
Encorafenib (Braftovi) Capsule
Endoscopic Radiofrequency Ablation or Cryosurgical Ablation for Barrett’s Esophagus
Endothelial Keratoplasty and Corneal Collagen Cross-Linking
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) and Extracranial Vertebral Artery Disease
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
Endovascular Stent Grafts for Disorders of the Thoracic Aorta
Enfortumab Vedotin-ejfv (Padcev) IV
Enteral Formulas
Entrectinib (Rozlytrek)
Enzalutamide (Xtandi) Capsules
Epidural Injections
Eptinezumab-jjmr (Vyepti)
Erdafitinib (Balversa)
Ergotamine (Ergomar)
Eribulin Mesylate (Halaven) Injection
Erlotinib (Tarceva) Tablets
Erythropoiesis Stimulating Agents
Esketamine (Spravato) Nasal Spray
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 Joint Injections
Fam-Trastuzumab Deruxtecan-nxki (Enhertu)
FDG-SPECT
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Microbiota Transplantation
Fedratinib (Inrebic) capsules
Fingolimod (Gilenya) Capsule
Fosnetupitant-Palonosetron (Akynzeo) IV
Fostamatinib (Tavalisse)
Fractionation and Radiation Therapy
Frenectomy or Frenotomy for Ankyloglossia (Tongue-Tie) in Newborns, Children, & Adolescents
Fulvestrant (Faslodex®) IM
Functional Magnetic Resonance Imaging (fMRI)
Functional Neuromuscular Stimulation
Gastric Electrical Stimulation
Gefitinib (Iressa)
Gemcitabine (Gemzar)
Gender Reassignment Surgery
Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
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
Gilteritinib (Xospata)
Givosiran (Givlaari) SQ
Glasdegib (Daurismo)
Glycerol Phenylbutyrate (Ravicti)
Golimumab (Simponi, Simponi Aria) Injection and Infusion
Golodirsen (Vyondys 53)
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])
Hydroxyprogesterone Caproate
Hyperalimentation
Hyperbaric Oxygen Therapy (Systemic, Topical)
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Ibandronate IV (Boniva) Injection
Ibrutinib (Imbruvica)
Idelalisib (Zydelig) Oral Tablet
Image-Guided Radiation Therapy
Imatinib Mesylate (Gleevec) Tablets
Immune Globulin Therapy
Implantable Bone-Conduction, Bone-Anchoring Hearing Aids
Implantable Cardioverter Defibrillators
Implantation of Intrastromal Corneal Ring Segments
In Utero (Intrauterine) Fetal Surgery
Inebilizumab (Uplizna) Injection
Infertility
Infliximab Products
Infrared Energy Therapy and Low Level Laser Therapy
Ingestible pH and Pressure Capsule
Inhaled Nitric Oxide
Injectable Bulking Agents for Treatment of Fecal Incontinence
Injectable Iron Therapy
Inotersen (Tegsedi)
Intensity-Modulated Radiation Therapy (IMRT)
Interspinous and Interlaminar Stabilization/Distraction (Spacers) and Fixation (Fusion) Devices
Interstitial Laser Therapy for Breast Tumors
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)
Isatuximab-irfc (Sarclisa) Infusion
Islet Cell Transplantation
Isolated Small Bowel Transplant
Ivacaftor (Kalydeco) Oral
Ivosidenib (Tibsovo)
Ixazomib (Ninlaro) Capsule
Ixekizumab (Taltz) Injection
Kidney Transplant
Knee Arthroplasty
Knee Arthroscopy and Open, Non-Arthroplasty Knee Repair
Knee Braces
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Laboratory Tests Post Transplant and for Heart Failure
Lanreotide (Somatuline Depot) Injection
Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids
Lapatinib (Tykerb) Tablets
Larotrectinib (Vitrakvi)
Laser Vitreolysis
Lenalidomide (Revlimid)
Lenvatinib (Lenvima)
Levoleucovorin (Fusilev, Khapzory)
Lisocabtagene Maraleucel (Breyanzi) Infusion
Liver Transplant and Combined Liver-Kidney Transplant
Lomitapide (Juxtapidâ„¢) Oral
Lorlatinib (Lorbrena)
Lower Limb Microprocessor-Controlled Prosthetics
Lumacaftor Ivacaftor (Orkambi) Capsule
Lumbar Spine Surgery
Lung and Lobar Lung Transplant
Luspatercept-aamt (Reblozyl)
Lusutrombopag (Mulpleta) Tablet
Lysis of Epidural Adhesions
Magnetic Resonance - Guided High Intensity Focused Ultrasound Ablation
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) Chest (Thorax)
Magnetic Resonance Imaging (MRI) Chest and Cardiac
Magnetic Resonance Imaging (MRI) Lower Extremity
Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck
Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar)
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 for Treatment of Joint Stiffness and Contractures
Medical & Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal Passages
Melphalan HCl, Captisol-Enabled (Evomela) IV Infusion
Mepolizumab (Nucala)
Metreleptin (Myaleptâ„¢) Injection
Midostaurin (Rydapt)
Mifepristone (Korlym) Oral
Migalastat (Galafold)
Minimally Invasive Fusion Techniques
Minimally Invasive Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) and Dysphagia
Mipomersen Sodium (Kynamro) Injection
Mogamulizumab-kpkc (Poteligeo) Injection
Mohs Micrographic Surgery
Molecular Testing for the Management of Pancreatic Cysts, Barrett Esophagus, and Solid Pancreatic Lesions
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 (Portrazza)
Negative Pressure Wound Therapy (NPWT)
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
Niraparib (Zejula) Capsule
Nitisinone (Orfadin®) Capsules
Nivolumab (Opdivo)
NK-1 receptor antagonist injectable therapy (Emend, Cinvanti)
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, Bynfezia Pen, Mycapssa Capsule)
Olaparib (Lynparza)
Olaratumab (Lartruvo)
Omacetaxine Mepesuccinate (Synriboâ„¢) Injection
Omalizumab (Xolair)
Onasemnogene abeparvovec (Zolgensma)
Ondansetron HCI (Zofran®) IV
Oral Oncology Medications
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
Osilodrostat (Isturisa)
Osimertinib (Tagrisso)
Outpatient Pulmonary Rehabilitation
Oxaliplatin (Eloxatin®) Injection
Oxygen
Ozanimod (Zeposia) Capsules
Palbociclib (Ibrance)
Palivizumab (Synagis)
Palonosetron Hydrochloride (Aloxi)
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
Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)
Pegloticase (Krystexxa) Infusion
Pegvaliase-pqpz (Palynziq)
Pelvic Floor Stimulation as a Treatment of Incontinence
Pembrolizumab (Keytruda) Injection
Pemetrexed Disodium (Alimta, Pemfexy) IV
Percutaneous Electrical Nerve Stimulation (PENS)
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Percutaneous Tibial Nerve Stimulation
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Pertuzumab (Perjeta) Injection
Pertuzumab, Trastuzumab, Hyaluronidase-zzxf (Phesgo)
PET Oncologic Applications
Pexidartinib (Turalio)
Photocoagulation of Macular Drusen
Physical Therapy (PT) and Occupational Therapy (OT)
Pimavanserin (Nuplazid)
Pirfenidone (Esbriet)
Pitolisant (Wakix)
Platelet-Derived Growth Factors and Platelet-Rich Plasma
Plerixafor (Mozobil) Injection
Plugs for Fistula Repair
Pneumatic Compression Devices
Polatuzumab vedotin-piiq (Polivy)
Pomalidomide (Pomalyst) Capsule
Ponatinib (Iclusig) Tablets
Positive Airway Pressure Devices
Positive Pressure Ventilation
Positron Emission Tomography (PET Scans) Cardiac Applications
Positron Emission Tomography (PET) Miscellaneous Applications
Pralatrexate (Folotyn) IV
Preventive Services
Private Duty Nursing Care in the Home
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)
Ravulizumab (Ultomiris) IV
Reconstructive Surgery/ Cosmetic Surgery
Reduction Mammaplasty
Regorafenib (Stivarga) Tablets
Remdesivir (Veklury)
Reslizumab (Cinqair) IV infusion
Ribociclib (Kisqali)
Rilonacept (Arcalyst®) Injection
Riluzole (Tiglutik)
Risankizumab-rzaa (Skyrizi) Injection
Risdiplam (Evrysdi)
Rituximab (Rituxan) and Rituximab hyaluronidase (Rituxan Hycela)
Romiplostim Injection (Nplate)
Romosozumab-aqqg (Evenity)
Rucaparib (Rubraca)
Ruxolitinib (Jakafi ) Oral
Sacituzumab Govitecan-hziy (Trodelvy)
Sacral Nerve Neuromodulation/Stimulation
Sacroiliac Joint Injections
Sacrosidase (Sucraid) Oral Solution
Sapropterin (Kuvan®) Tablets
Sarilumab (Kevzara) Injection
SARS-CoV-2 Monoclonal Antibodies
Satralizumab (Enspryng)
Scanning Computerized Ophthalmic Diagnostic Imaging
Scintimammography and Gamma Imaging of the Breast
Secukinumab (Cosentyx) Injection
Selective Internal Radiation Therapy
Selinexor (Xpovio) Tablet
Signal Averaged Electrocardiography (SAECG)
Siltuximab (Sylvantâ„¢) Injection
Siponimod (Mayzent) tablets
Sipuleucel-T (Provenge)
Site of Care Guideline for Select Specialty Medications
Sleep Testing
Small Bowel, Liver and Multivisceral Transplant
Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybates (Xywav) Oral Solutions
Sodium Phenylbutyrate (Buphenyl)
Sonidegib (Odomzo) Capsule
Sorafenib (Nexavar) Tablets
Special Treatment Procedure and Special Physics Consult
Speech Generating Devices
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
Tafamidis (Vyndamax, Vyndaqel) Oral
Tafasitamab-cxix (Monjuvi) IV Infusion
Talazoparib (Talzenna)
Tasimelteon (Hetlioz) 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
Temsirolimus (Torisel) Injection
Tendon Sheath, Ligament, and Trigger Point Injections
Teprotumumab (Tepezza) Infusion
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)
Thoracic Electrical Bioimpedance (TEB)
Thumb Basal Joint Arthroscopy
Tildrakizumab-asmn (Ilumya)
Tiopronin (Thiola, Thiola EC) Tablet
Tisagenlecleucel (Kymriah) Infusion
Tocilizumab (Actemra) Injection and Infusion
Tofacitinib (Xeljanz, Xeljanz XR) Tablets
Tolvaptan (Jynarque) Tablet
Tolvaptan (Samscaâ„¢) Oral
Topotecan HCl (Hycamtin) Injection and Capsule
Total Ankle Replacement
Total Body Plethysmography
Total Facet Arthroplasty
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
Triheptanoin (Dojolvi) Oral Liquid
Tumor Genetic Markers
Tumor Treatment Fields Therapy
Ultrasound in Maternity Care
Ultrasound Osteogenesis Stimulators, Non-invasive
Unclassified Codes and Compounded Drug Products
Unicondylar Interpositional Spacer Devices
Upadacitinib (Rinvoq)
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
Viltolarsen (Viltepso)
Vinorelbine Tartrate (Navelbine®) IV
Viscocanalostomy and Canaloplasty
Viscosupplementation, Hyaluronan Injections (e.g. Synvisc®)
Vismodegib (Erivedge) Capsules
Vitamin B-12 Injections
Voretigene Neparvovec-rzyl (Luxturna) Injection
Vorinostat (Zolinza) Capsules
Voxelotor (Oxbryta)
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
Zanubrutinib (Brukinsa)
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
Blepharoplasty and Brow Surgical Procedures CMN
Blood Glucose Monitors and Supplies CMN
Heart and Lung Transplant CMN
Heart Transplant CMN
Hyperalimentation CMN
Kidney Transplantation CMN
Liver Transplant CMN
Lung and Lobar Lung Transplant CMN
Mechanical Stretching Devices CMN
Nerve Block Injections CMN
Outpatient Pulmonary Rehabilitation Services CMN
Pancreatic Islet Cell Transplantation CMN
Scanning Computerized Ophthalmic Diagnostic Imaging CMN
Septoplasty CMN
Small Bowel Transplant CMN
Small Bowel, Liver, and Multivisceral Transplant CMN
Speech Therapy CMN
Wheelchairs and Wheelchair Components CMN
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