Home
Medical Coverage Guidelines
Open the calendar popup.
<<
<
August 2024
>
>>
S
M
T
W
T
F
S
31
28
29
30
31
1
2
3
32
4
5
6
7
8
9
10
33
11
12
13
14
15
16
17
34
18
19
20
21
22
23
24
35
25
26
27
28
29
30
31
36
1
2
3
4
5
6
7
Search
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
Durable Medical Equipment (DME)
Electrostimulation and Electromagnetic Therapy for Treating Wounds
External Infusion Pumps (non-insulin)
External Insulin Infusion Pumps and Continuous Glucose Monitors
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 Used in the Home 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 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
Tumor Treating Fields Therapy
Ultrasound Osteogenesis Stimulators, Non-invasive
Wheelchairs and Wheelchair Accessories
Medicine
Adoptive Immunotherapy
Allergy Testing and Immunotherapy
Ambulatory Blood Pressure Monitoring (ABPM)
Apheresis, Plasmapheresis and Plasma Exchange
Autonomic Nervous System Testing
Balloon Dilation of the Eustachian Tube
Biofeedback
Cardiac Monitoring Devices
Chelation Therapy
Cognitive Rehabilitation
Complications of Pregnancy
Diabetic Self-Management Training and Educational Supplies
Diagnosis and Treatment of Temporomandibular Joint Disorder
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
Foot Care Services
Gastric Electrical Stimulation
Home Prothrombin Time Monitoring
Hyperbaric Oxygen Therapy (Systemic & Topical)
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Ingestible pH and Pressure Capsule
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 Medical Nutrition Therapy
Outpatient Pulmonary Rehabilitation
Pelvic Floor Stimulation as a Treatment of Incontinence
Percutaneous and Subcutaneous Tibial Nerve Stimulation
Physical Therapy (PT) and Occupational Therapy (OT)
Preventive Services
Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)
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
Functional Neuromuscular Stimulation
Knee Braces
Lower Limb Microprocessor-Controlled Prosthetics
Myoelectric Prosthetic Components for the Upper Limb
Orthotics
Prosthetics
Other
Enteral Formulas
Home Health Care
Home Parenteral Nutrition
Hospice Care
Injectable Bulking Agents for Treatment of Urinary and 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
Adjunctive Techniques for Screening and Surveillance of Barrett’s Esophagus and Esophageal Dysplasia
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
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
In Vitro Chemoresistance and Chemosensitivity Assays
Intracellular Micronutrient Analysis
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, Twin Zygosity, and Microdeletions Using Cell-Free Fetal DNA
Somatic Biomarker Testing (KRAS, NRAS, BRAF, HER2), Including Liquid Biopsy and MicroRNA Expression Testing, in Metastatic Colorectal Cancer
Sparsentan (Filspari)
Tumor Genetic Markers
Pharmacy
Abaloparatide (Tymlos)
Abatacept (Orencia) Injection and Infusion
Abemaciclib (Verzenio)
Abiraterone Acetate (Yonsa, Zytiga) Tablet
Abrocitinib (Cibinqo) Tablets
Acalabrutinib (Calquence) Oral
Adalimumab Products (Humira and biosimilars)
ADAMTS13, recombinant-krhn (Adzynma) IV Infusion
Ado-trastuzumab emtansine (Kadcyla)
Aducanumab-avwa (Aduhelm)
Afamelanotide (Scenesse) Implant
Afatinib (Gilotrif) Tablets
Agalsidase Beta (Fabrazyme) IV
Alectinib (Alecensa)
Alemtuzumab (Lemtrada) IV
Allogeneic Processed Thymus Tissue_agdc (Rethymic)
Alpelisib (Piqray) Tablet
Alpelisib (Vijoice)
Alpha1-Proteinase Inhibitors (Human)
Amifampridine Phosphate (Firdapse)
Amivantamab-vmjw (Rybrevant)
Anakinra (Kineret) Injection
Anifrolumab-fnia (Saphnelo) IV Infusion
Apalutamide (Erleada) Tablet
Apremilast (Otezla) Tablet
Aprepitant injectable therapy (Cinvanti)
Asciminib (Scemblix) Tablet
Asfotase alfa (Strensiq)
Atidarsagene autotemcel (Lenmeldy) suspension for IV infusion
Avacincaptad pegol (Izervay) intravitreal injection
Avacopan (Tavneos)
Avapritinib (Ayvakit)
Avatrombopag (Doptelet)
Axicabtagene Ciloleucel (Yescarta) Infusion
Axitinib (Inlyta) Tablets
Azacitidine (Vidaza) Injection
Baricitinib (Olumiant) Tablet
Belantamab Mafodotin-blmf (Blenrep) IV Infusion
Belimumab (Benlysta) Injection
Belinostat (Beleodaq) Injection
Belumosudil (Rezurock) Tablets
Bendamustine HCL Injection
Benralizumab (Fasenra)
Beremagene Geperpavec-svdt (Vyjuvek) Biological Suspension
Betaine, anhydrous (Cystadane) Oral Solution
Betibeglogene Autotemcel (Zynteglo) IV Infusion
Bevacizumab (Avastin), bevacizumab-awwb (Mvasi), bevacizumab-bvzr (Zirabev), and bevacizumab-maly (Alymsys), bevacizumab-tnjn (Avzivi), and bevacizumab-adcd (Vegzelma) Injection
Bexarotene (Targretin) Capsules
Bezlotoxumab (Zinplava) Injection
Bimekizumab-bkzx (Bimzelx) Injection
Binimetinib (Mektovi) Tablet
Birch Triterpenes (Filsuvez)
Blinatumomab (Blincyto) IV
Bortezomib (Velcade) Injection
Bosutinib (Bosulif) Capsules and Tablets
Botulinum Toxins
Brand (Aubagio) Tablet
Brand Gilenya Capsule and Tascenso ODT
Brand Tecfidera, Diroximel fumarate (Vumerity), Monomethyl fumarate (Bafiertam) Capsule
Brentuximab (Adcetris) Injection
Brexanolone (Zulresso) IV Infusion
Brexucabtagene Autoleucel (Tecartus) Infusion
Brigatinib (Alunbrig)
Brodalumab (Siliq) Injection
Budesonide (Tarpeyo)
Buprenorphine HCl (Probuphine) Subdermal Implant and Buprenorphine (Brixadi, Sublocade) Subcutaneous Injection
Burosumab (Crysvita)
Cabazitaxel Injection
Cabozantinib Capsules and Tablets (Cometriq, Cabometyx)
Canakinumab (Ilaris) Injection
Cannabidiol (Epidiolex)
Cantharidin (Ycanth)
Capecitabine (Xeloda) Tablets
Caplacizumab-yhdp (Cablivi)
Carboplatin (Paraplatin) IV
Carfilzomib (Kyprolis) Injection
Cenegermin-bkbj (Oxervate)
Ceritinib (Zykadia) Capsules
Certolizumab Pegol (Cimzia) Injection
Chimeric Antigen Receptor (CAR) T-Cell Therapies
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)
Danicopan (Voydeya)
Daprodustat (Jesduvroq)
Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection
Darolutamide (Nubeqa)
Dasatinib (Sprycel) Tablets
Deflazacort (Emflaza)
Delandistrogene moxeparvovec (Elevidys)
Denosumab (Prolia, Xgeva) Injection
Deucravacitinib (Sotyktu) Tablet
Dichlorphenamide (Keveyis)
Dinutuximab (Unituxin)
Docetaxel (Taxotere) IV
Donislecel (Lantidra) Allogenic Islet Cell Transplant
Dostarlimab-gxly (Jemperli)
Doxorubicin HCl Liposome (Doxil) Injection
Droxidopa (Northera)
Drugs and Biologics without Medical Coverage Guideline
Dupilumab (Dupixent) Injection
Duvelisib (Copiktra)
Eculizumab (Soliris) Injection
Edaravone (Radicava)
Efgartigimod (Vyvgart, Vyvgart Hytrulo) Injection
Elapegademase-lvlr (Revcovi) Injection
Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)
Elivaldogene autotemcel (Skysona)
Elosulfase alfa (Vimizimâ„¢) Injection
Elotuzumab (Empliciti) Injection
Elranatamab-bcmm (Elrexfio) Subcutaneous 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
Enzyme Replacement Therapy for Pompe Disease
Epcoritamab-bysp (Epkinly) SQ Injection
Eplontersen (Wainua)
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)
Etranacogene Dezaparvovec (Hemgenix)
Etrasimod (Velsipity) Tablet
Everolimus (Afinitor, Afinitor Disperz) Tablets
Evinacumab-dgnb (Evkeeza) Infusion
Exagamglogene autotemcel (Casgevy) suspension for IV infusion
Exon-skipping Therapy for Duchenne Muscular Dystrophy
Fam-Trastuzumab Deruxtecan-nxki (Enhertu)
Fedratinib (Inrebic) Capsules
Fosdenopterin Hydrobromide (Nulibry) IV Infusion
Fosnetupitant-Palonosetron (Akynzeo) IV
Fostamatinib (Tavalisse)
Fulvestrant (Faslodex®) IM
Furosemide (Furoscix) subcutaneous infusion
Ganaxolone (Ztalmy) Oral Suspension
Gefitinib (Iressa)
Gilteritinib (Xospata)
Givosiran (Givlaari) SQ
Glasdegib (Daurismo)
Glofitamab-gxbm (Columvi) IV Infusion
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, Purified Cortrophin® Gel (Repository corticotropin)
Hepatitis C Drug Therapy
Hereditary Angioedema Drug Therapy
Hormone Replacement
Human EGFR Inhibitors (Cetuximab [Erbitux], Panitumumab [Vectibix])
Hydroxyprogesterone Caproate
Ibrutinib (Imbruvica)
Idelalisib (Zydelig) Oral Tablet
Imatinib Mesylate (Gleevec) Tablets
Immune Globulin Therapy
Inclisiran (Leqvio) Injection
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
Iptacopan (Fabhalta) Capsules
Irinotecan Liposome Injection (Onivyde)
Isatuximab-irfc (Sarclisa) Infusion
Ivacaftor (Kalydeco) Oral
Ivosidenib (Tibsovo)
Ixazomib (Ninlaro) Capsule
Ixekizumab (Taltz) Injection
Lanreotide (Somatuline Depot, Lanreotide acetate) Injection
Lapatinib (Tykerb) Tablets
Larotrectinib (Vitrakvi)
Lecanemab-irmb (Leqembi) intravenous infusion
Lenalidomide (Revlimid)
Leniolisib Phosphate (Joenja)
Lenvatinib (Lenvima)
Levoketoconazole (Recorlev) tablets
Levoleucovorin (Fusilev, Khapzory)
Lifileucel (Amtagvi) suspension for IV infusion
Lisocabtagene Maraleucel (Breyanzi)
Lomitapide (Juxtapidâ„¢) Oral
Lonafarnib (Zokinvy)
Loncastuximab Tesirine-lpyl (Zynlonta)
Lorlatinib (Lorbrena)
Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion
Lumacaftor Ivacaftor (Orkambi) Capsule
Lumasiran (Oxlumo) Injection
Luspatercept-aamt (Reblozyl)
Lusutrombopag (Mulpleta) Tablet
Maralixibat (Livmarli)
Margetuximab-cmkb (Margenza)
Maribavir (Livtencity).doc
Mavacamten (Camzyos) 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
Mirikizumab-mrkz (Omvoh) Injection and Infusion
Mitapivat (Pyrukynd)
Mogamulizumab-kpkc (Poteligeo) Injection
Momelotinib (Ojjaara) Tablets
Multiple Sclerosis Self Injectable Therapy (Interferon beta products and Copaxone)
Nab-Paclitaxel Injection (Abraxane)
Natalizumab (Tysabri) IV
Naxitamab-gqgk (Danyelza) Injection
Necitumumab (Portrazza)
Nedosiran (Rivfloza) subcutaneous injection
Neratinib (Nerlynx)
New-To-Market Program for Provider-Administered Medications
Nilotinib (Tasigna) Capsules
Nintedanib (Ofev) Oral
Niraparib (Zejula) Capsule
Nitisinone (Orfadin®) Capsules
Nivolumab (Opdivo)
Nivolumab, Relatlimab-rmbw (Opdualag) injection
Nusinersen (Spinraza)
Obeticholic Acid (Ocaliva) Tablet
Obinutuzumab (Gazyva) Injection
Ocrelizumab (Ocrevus) Infusion
Octreotide Acetate (Sandostatin LAR Depot, Bynfezia Pen, Mycapssa Capsule)
Odevixibat (Bylvay)
Ofatumumab (Kesimpta)
Olaparib (Lynparza)
Olipudase Alfa-rpcp (Xenpozyme)
Omacetaxine Mepesuccinate (Synriboâ„¢) Injection
Omadacycline (Nuzyra) Tablet
Omalizumab (Xolair)
Omaveloxolone (Skyclarys) Oral Capsule
Onasemnogene abeparvovec (Zolgensma)
Ondansetron HCI (Zofran®) IV
Oral Oncology Medications
Oral Therapy for Gaucher and Pompe Disease
Osilodrostat (Isturisa)
Osimertinib (Tagrisso)
Oxybate Oral Solutions (Sodium Oxybate, Xyrem, and Xywav) and Suspension (Lumryz)
Ozanimod (Zeposia)
Pacritinib (Vonjo) Capsule
Palbociclib (Ibrance)
Palivizumab (Synagis)
Palovarotene (Sohonos) Oral Capsules
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)
Pegcetacoplan (Empaveli) SC Infusion
Pegcetacoplan (Syfovre) intravitreal injection
Pegloticase (Krystexxa)
Pegunigalsidase (Elfabrio) IV
Pegvaliase-pqpz (Palynziq)
Pembrolizumab (Keytruda) Injection
Pemetrexed (Alimta, Pemfexy) IV
Pertuzumab (Perjeta) Injection
Pertuzumab, Trastuzumab, Hyaluronidase-zzxf (Phesgo)
Pexidartinib (Turalio)
Pimavanserin (Nuplazid)
Pirfenidone (Esbriet)
Pitolisant (Wakix)
Plasminogen, Human-tmvh (Ryplazim) IV Infusion
Plerixafor (Mozobil) Injection
Polatuzumab vedotin-piiq (Polivy) Infusion
Pomalidomide (Pomalyst) Capsule
Ponatinib (Iclusig) Tablets
Ponesimod (Ponvory) Tablet
Pozelimab-bbfg (Veopoz)
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 or Subcutaneous
Regorafenib (Stivarga) Tablets
Remdesivir (Veklury)
Reslizumab (Cinqair) IV infusion
Resmetirom (Rezdiffra) tablets
Ribociclib (Kisqali)
Rilonacept (Arcalyst) Injection
Riluzole (Tiglutik, Exservan)
Risankizumab-rzaa (Skyrizi) Injectionand Infusion
Risdiplam (Evrysdi)
Ritlecitinib (Litfulo) Capsule
Rituximab Products
Romiplostim Injection (Nplate)
Romosozumab-aqqg (Evenity)
Ropeginterferon alfa-2b-njft (Besremi)
Rozanolixizumab-noli (Rystiggo) Injection
Rucaparib (Rubraca)
Ruxolitinib (Jakafi ) Oral
Sacituzumab Govitecan-hziy (Trodelvy)
Sacrosidase (Sucraid) Oral Solution
Sapropterin (Kuvan®) Tablets
Sarilumab (Kevzara) Injection
SARS-CoV-2 (COVID-19) Testing
SARS-CoV-2 Monoclonal Antibodies
Satralizumab (Enspryng)
Secukinumab (Cosentyx) Injection and Infusion
Selinexor (Xpovio) Tablet
Setmelanotide (Imcivree) Injection
Siltuximab (Sylvantâ„¢) Injection
Siponimod (Mayzent) tablets
Sipuleucel-T (Provenge)
Site of Care Guideline for Select Specialty Medications
Sodium Phenylbutyrate (Buphenyl, Olpruva, and Pheburane)
Sodium phenylbutyrate-taurursodiol (Relyvrio) for oral suspension
Sonidegib (Odomzo) Capsule
Sorafenib (Nexavar) Tablets
Spesolimab-sbzo (Spevigo) Subcutaneous Injection and Intravenous Infusion
Step Therapy Requirements for Medicare Outpatient (Part B) Medications
Sunitinib Malate (Sutent) Capsules
Sutimlimab-jome (Enjaymo) Injection
Tafamidis (Vyndamax, Vyndaqel) Oral
Tafasitamab-cxix (Monjuvi) IV Infusion
Talazoparib (Talzenna)
Talquetamab-tgvs (Talvey) Subcutaneous Injection
Tasimelteon (Hetlioz) Capsules
Tebentafusp-tebn (Kimmtrak) IV Infusion
Teclistamab (Tecvayli) Injection
Teduglutide (rDNA origin)(Gattex) Injection
Temozolomide (Temodar) Capsule and Injection
Temsirolimus (Torisel) Injection
Teplizumab (Tzield) Injection
Teprotumumab (Tepezza) Infusion
Teriparatide (Forteo)
Tesamorelin (Egrifta) Injection
Tetrabenazine (Xenazine) and Deutetrabenazine (Austedo, Austedo XR)
Tezacaftor-Ivacaftor (Symdeko)
Tezepelumab-ekko (Tezspire)
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, Tocilizumab-aazg (Tyenne) Injection and Infusion, and Tocilizumab-bavi (Tofidence) Infusion
Tofacitinib (Xeljanz, Xeljanz XR) Oral Solution, Tablet and Extended-Release Tablet
Tofersen (Qalsody) Intrathecal Injection
Tolvaptan (Jynarque) Tablet
Tolvaptan (Samscaâ„¢) Oral
Topotecan HCl (Hycamtin) Injection and Capsule
Tralokinumab-ldrm (Adbry) Injection
Trametinib (Mekinist) Tablets
Trastuzumab (Herceptin) Injection
Tretinoin Oral Capsules
Trifluridine-Tipiracil (Lonsurf) Capsule
Triheptanoin (Dojolvi) Oral Liquid
Trilaciclib (Cosela) IV infusion
Trofinetide (Daybue) Oral Solution
Ublituximab-xiiy (Briumvi)
Unclassified Codes and Compounded Drug Products
Upadacitinib Tablet (Rinvoq) and Oral Solution (Rinvoq LQ)
Ustekinumab (Stelara) Injection and Infusion
Vadadustat (Vafseo)
Valbenazine (Ingrezza)
Valoctocogene Roxaparvovec-rvox (Roctavian)
Vamorolone (Agamree) Oral Solution
Vandetanib (Caprelsa) Tablets
Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization
Vedolizumab (Entyvio) Injection and Infusion
Velmanase alfa-tycv (Lamzede) intravenous 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
Voclosporin (Lupkynis)
Voretigene Neparvovec-rzyl (Luxturna) Injection
Vorinostat (Zolinza) Capsules
Vosoritide (Voxzogo)
Voxelotor (Oxbryta)
Vutrisiran (Amvuttra)
Zanubrutinib (Brukinsa)
Zilucoplan (Zilbrysq) Subcutaneous Injection
Ziv-aflibercept (Zaltrap) IV
Zuranolone (Zurzuvae) Oral Capsules
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 and 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
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)
Magnetoencephalography/Magnetic Source Imaging
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
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 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
Computer-Assisted Navigation for Orthopedic Procedures
Cryoablation of Liver Tumors
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Deep Brain Stimulation and Responsive Neurostimulation
Dermabrasion, Chemical Peel, Salabrasion, and Acne Surgery
Diaphragmatic/Phrenic Nerve Stimulation (i.e., Electrophrenic Pacemaker)
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
Excimer Laser Therapy for Treatment of Dermatologic Conditions
Extracranial Carotid Angioplasty Stenting
Facet Arthroplasty
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, Cardiac Contractility Modulation (CCM) Therapy
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 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
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
Microwave Tumor Ablation Other Than Liver Tumors
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 and Intraosseous Basivertebral Nerve Ablation
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
Radiofrequency Ablation of Solid Tumors Other Than Liver Tumors
Radiofrequency and Microwave Ablation of 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
Surgical Treatments for Lymphedema and Lipedema
Temporary Prostatic Urethral Stents (Including Implantable Nitinol Devices) and Prostatic Urethral Lift
Thoracic and Lumbar Spine Surgery
Thumb Basal Joint Arthroscopy
Total Ankle Replacement
Total Artificial Hearts and Implantable Ventricular Assist Devices
Transanal Endoscopic Microsurgery
Transcatheter Aortic Valve Replacement
Transcatheter Mitral Valve Repair (TMVR)
Transcatheter Pulmonary Valve Implantation
Transmyocardial Revascularization (TMR)
Transurethral Waterjet Ablation of the Prostate
Transvaginal Radiofrequency Bladder Neck Suspension and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Treatments for Varicose Veins Venous Insufficiency
Trigger Point Injections
Unicondylar Interpositional Spacer Devices
Vagus Nerve Stimulation
Viscocanalostomy and Canaloplasty
Whole Gland Cryoablation of Prostate Cancer (CSAP)
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)
Implantation of Intrastromal Corneal Ring Segments
Prosthetic Eyes and Lens Implants
Scanning Computerized Ophthalmic Diagnostic Imaging
Alphabetical
Abaloparatide (Tymlos)
Abatacept (Orencia) Injection and Infusion
Abemaciclib (Verzenio)
Abiraterone Acetate (Yonsa, Zytiga) Tablet
Abortion
Abrocitinib (Cibinqo) Tablets
Acalabrutinib (Calquence) Oral
Adalimumab Products (Humira and biosimilars)
ADAMTS13, recombinant-krhn (Adzynma) IV Infusion
Adjunctive Techniques for Screening and Surveillance of Barrett’s Esophagus and Esophageal Dysplasia
Ado-trastuzumab emtansine (Kadcyla)
Adoptive Immunotherapy
Aducanumab-avwa (Aduhelm)
Afamelanotide (Scenesse) Implant
Afatinib (Gilotrif) Tablets
Agalsidase Beta (Fabrazyme) IV
Alectinib (Alecensa)
Alemtuzumab (Lemtrada) IV
Allergy Testing and Immunotherapy
Allogeneic Allogeneic Hematopoietic Cell Transplantation
Allogeneic Pancreas Transplant
Allogeneic Processed Thymus Tissue_agdc (Rethymic)
Alpelisib (Piqray) Tablet
Alpelisib (Vijoice)
Alpha1-Proteinase Inhibitors (Human)
Ambulance Services
Ambulatory Blood Pressure Monitoring (ABPM)
Amifampridine Phosphate (Firdapse)
Amivantamab-vmjw (Rybrevant)
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
Anifrolumab-fnia (Saphnelo) IV Infusion
Apalutamide (Erleada) Tablet
Apheresis, Plasmapheresis and Plasma Exchange
Apremilast (Otezla) Tablet
Aprepitant injectable therapy (Cinvanti)
Aqueous Shunts and Stents for Glaucoma
Asciminib (Scemblix) Tablet
Asfotase alfa (Strensiq)
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Atidarsagene autotemcel (Lenmeldy) suspension for IV infusion
Auditory Integration Training (AIT)
Autologous Chondrocyte Implantation (ACI)
Autologous Hematopoietic Cell Transplantation
Automated Percutaneous Discectomy, Laser Discectomy, Percutaneous Endoscopic Discectomy, and DISC Nucleoplasty
Autonomic Nervous System Testing
Avacincaptad pegol (Izervay) intravitreal injection
Avacopan (Tavneos)
Avapritinib (Ayvakit)
Avatrombopag (Doptelet)
Axicabtagene Ciloleucel (Yescarta) Infusion
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
Belumosudil (Rezurock) Tablets
Bendamustine HCL Injection
Benralizumab (Fasenra)
Beremagene Geperpavec-svdt (Vyjuvek) Biological Suspension
Betaine, anhydrous (Cystadane) Oral Solution
Betibeglogene Autotemcel (Zynteglo) IV Infusion
Bevacizumab (Avastin), bevacizumab-awwb (Mvasi), bevacizumab-bvzr (Zirabev), and bevacizumab-maly (Alymsys), bevacizumab-tnjn (Avzivi), and bevacizumab-adcd (Vegzelma) Injection
Bexarotene (Targretin) Capsules
Bezlotoxumab (Zinplava) Injection
Bimekizumab-bkzx (Bimzelx) Injection
Binimetinib (Mektovi) Tablet
Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid
Biofeedback
Birch Triterpenes (Filsuvez)
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) Capsules and Tablets
Botulinum Toxins
Brachytherapy - Oncologic Applications
Brand (Aubagio) Tablet
Brand Gilenya Capsule and Tascenso ODT
Brand Tecfidera, Diroximel fumarate (Vumerity), Monomethyl fumarate (Bafiertam) Capsule
Breast Ductoscopy
Brentuximab (Adcetris) Injection
Brexanolone (Zulresso) IV Infusion
Brexucabtagene Autoleucel (Tecartus) Infusion
Brigatinib (Alunbrig)
Brodalumab (Siliq) Injection
Bronchial Thermoplasty
Budesonide (Tarpeyo)
Buprenorphine HCl (Probuphine) Subdermal Implant and Buprenorphine (Brixadi, Sublocade) Subcutaneous Injection
Burosumab (Crysvita)
Cabazitaxel Injection
Cabozantinib Capsules and Tablets (Cometriq, Cabometyx)
Canakinumab (Ilaris) Injection
Cannabidiol (Epidiolex)
Cantharidin (Ycanth)
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
Chimeric Antigen Receptor (CAR) T-Cell Therapies
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 and 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
Corticosteroid Intravitreal Implant
Cranial Orthosis for Craniosynostoses and Plagiocephaly
Crizanlizumab-tmca (Adakveo)
Crizotinib (Xalkori) Capsules
Cryoablation of Liver Tumors
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Cysteamine products (Procysbi, Cystadrops, Cystaran)
Dabrafenib (Tafinlar) Capsules
Dacomitinib (Vizimpro)
Danicopan (Voydeya)
Daprodustat (Jesduvroq)
Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection
Darolutamide (Nubeqa)
Dasatinib (Sprycel) Tablets
Deep Brain Stimulation and Responsive Neurostimulation
Deflazacort (Emflaza)
Delandistrogene moxeparvovec (Elevidys)
Denosumab (Prolia, Xgeva) Injection
Dermabrasion, Chemical Peel, Salabrasion, and Acne Surgery
Deucravacitinib (Sotyktu) Tablet
Diabetic Self-Management Training and Educational Supplies
Diagnosis and Treatment of Temporomandibular Joint Disorder
Diaphragmatic/Phrenic Nerve Stimulation (i.e., Electrophrenic Pacemaker)
Dichlorphenamide (Keveyis)
Dinutuximab (Unituxin)
Docetaxel (Taxotere) IV
Donislecel (Lantidra) Allogenic Islet Cell Transplant
Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography
Dostarlimab-gxly (Jemperli)
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)
Efgartigimod (Vyvgart, Vyvgart Hytrulo) Injection
Elapegademase-lvlr (Revcovi) Injection
Electroretinography
Electrostimulation and Electromagnetic Therapy for Treating Wounds
Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)
Elivaldogene autotemcel (Skysona)
Elosulfase alfa (Vimizimâ„¢) Injection
Elotuzumab (Empliciti) Injection
Elranatamab-bcmm (Elrexfio) Subcutaneous 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
Enzyme Replacement Therapy for Pompe Disease
Epcoritamab-bysp (Epkinly) SQ Injection
Epidural Injections
Eplontersen (Wainua)
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)
Etranacogene Dezaparvovec (Hemgenix)
Etrasimod (Velsipity) Tablet
Everolimus (Afinitor, Afinitor Disperz) Tablets
Evinacumab-dgnb (Evkeeza) Infusion
Evoked Potentials, Intraoperative Neurophysiologic Monitoring, and Quantitative Electroencephalography (QEEG)
Exagamglogene autotemcel (Casgevy) suspension for IV infusion
Excimer Laser Therapy for Treatment of Dermatologic Conditions
Exon-skipping Therapy for Duchenne Muscular Dystrophy
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
Fam-Trastuzumab Deruxtecan-nxki (Enhertu)
FDG-SPECT
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Microbiota Transplantation
Fedratinib (Inrebic) Capsules
Foot Care Services
Fosdenopterin Hydrobromide (Nulibry) IV Infusion
Fosnetupitant-Palonosetron (Akynzeo) IV
Fostamatinib (Tavalisse)
Frenectomy or Frenotomy for Ankyloglossia (Tongue-Tie) in Newborns, Children, & Adolescents
Fulvestrant (Faslodex®) IM
Functional Magnetic Resonance Imaging (fMRI)
Functional Neuromuscular Stimulation
Furosemide (Furoscix) subcutaneous infusion
Ganaxolone (Ztalmy) Oral Suspension
Gastric Electrical Stimulation
Gefitinib (Iressa)
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)
Glofitamab-gxbm (Columvi) IV Infusion
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, Purified Cortrophin® 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 Parenteral Nutrition
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
Hyperbaric Oxygen Therapy (Systemic & Topical)
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
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, Cardiac Contractility Modulation (CCM) Therapy
Implantation of Intrastromal Corneal Ring Segments
In Utero (Intrauterine) Fetal Surgery
In Vitro Chemoresistance and Chemosensitivity Assays
Inclisiran (Leqvio) Injection
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 Urinary and 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
Iptacopan (Fabhalta) Capsules
Irinotecan Liposome Injection (Onivyde)
Irreversible Electroporation (IRE)
Isatuximab-irfc (Sarclisa) Infusion
Islet 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
Laboratory Tests Post Transplant and for Heart Failure
Lanreotide (Somatuline Depot, Lanreotide acetate) Injection
Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids
Lapatinib (Tykerb) Tablets
Larotrectinib (Vitrakvi)
Laser Vitreolysis
Lecanemab-irmb (Leqembi) intravenous infusion
Lenalidomide (Revlimid)
Leniolisib Phosphate (Joenja)
Lenvatinib (Lenvima)
Levoketoconazole (Recorlev) tablets
Levoleucovorin (Fusilev, Khapzory)
Lifileucel (Amtagvi) suspension for IV infusion
Lisocabtagene Maraleucel (Breyanzi)
Liver Transplant and Combined Liver-Kidney Transplant
Lomitapide (Juxtapidâ„¢) Oral
Lonafarnib (Zokinvy)
Loncastuximab Tesirine-lpyl (Zynlonta)
Lorlatinib (Lorbrena)
Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion
Lower Limb Microprocessor-Controlled Prosthetics
Lumacaftor Ivacaftor (Orkambi) Capsule
Lumasiran (Oxlumo) Injection
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
Maralixibat (Livmarli)
Margetuximab-cmkb (Margenza)
Maribavir (Livtencity).doc
Mastectomy for Gynecomastia
Mavacamten (Camzyos) Tablet
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 and 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
Microwave Tumor Ablation Other Than Liver Tumors
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
Mirikizumab-mrkz (Omvoh) Injection and Infusion
Mitapivat (Pyrukynd)
Mogamulizumab-kpkc (Poteligeo) Injection
Mohs Micrographic Surgery
Molecular Testing for the Management of Pancreatic Cysts, Barrett Esophagus, and Solid Pancreatic Lesions
Momelotinib (Ojjaara) Tablets
Multiple Gated Acquisition Scan (MUGA)
Multiple Sclerosis Self Injectable Therapy (Interferon beta products and Copaxone)
Myoelectric Prosthetic Components for the Upper Limb
Nab-Paclitaxel Injection (Abraxane)
Natalizumab (Tysabri) IV
Naxitamab-gqgk (Danyelza) Injection
Necitumumab (Portrazza)
Nedosiran (Rivfloza) subcutaneous injection
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
New-To-Market Program for Provider-Administered Medications
Nilotinib (Tasigna) Capsules
Nintedanib (Ofev) Oral
Niraparib (Zejula) Capsule
Nitisinone (Orfadin®) Capsules
Nivolumab (Opdivo)
Nivolumab, Relatlimab-rmbw (Opdualag) injection
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, Twin Zygosity, 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)
Odevixibat (Bylvay)
Ofatumumab (Kesimpta)
Olaparib (Lynparza)
Olipudase Alfa-rpcp (Xenpozyme)
Omacetaxine Mepesuccinate (Synriboâ„¢) Injection
Omadacycline (Nuzyra) Tablet
Omalizumab (Xolair)
Omaveloxolone (Skyclarys) Oral Capsule
Onasemnogene abeparvovec (Zolgensma)
Ondansetron HCI (Zofran®) IV
Oral Oncology Medications
Oral Therapy for Gaucher and Pompe Disease
Orthognathic Surgery
Orthopedic Applications of Stem-Cell Therapy
Orthotics
Oscillatory Devices Used in the Home for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
Osilodrostat (Isturisa)
Osimertinib (Tagrisso)
Outpatient Medical Nutrition Therapy
Outpatient Pulmonary Rehabilitation
Oxybate Oral Solutions (Sodium Oxybate, Xyrem, and Xywav) and Suspension (Lumryz)
Oxygen
Ozanimod (Zeposia)
Pacritinib (Vonjo) Capsule
Palbociclib (Ibrance)
Palivizumab (Synagis)
Palovarotene (Sohonos) Oral Capsules
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)
Pegcetacoplan (Empaveli) SC Infusion
Pegcetacoplan (Syfovre) intravitreal injection
Pegloticase (Krystexxa)
Pegunigalsidase (Elfabrio) IV
Pegvaliase-pqpz (Palynziq)
Pelvic Floor Stimulation as a Treatment of Incontinence
Pembrolizumab (Keytruda) Injection
Pemetrexed (Alimta, Pemfexy) IV
Percutaneous and Subcutaneous Tibial Nerve Stimulation
Percutaneous Electrical Nerve Stimulation (PENS)
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty and Intraosseous Basivertebral Nerve Ablation
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Pertuzumab (Perjeta) Injection
Pertuzumab, Trastuzumab, Hyaluronidase-zzxf (Phesgo)
Pexidartinib (Turalio)
Photocoagulation of Macular Drusen
Physical Therapy (PT) and Occupational Therapy (OT)
Pimavanserin (Nuplazid)
Pirfenidone (Esbriet)
Pitolisant (Wakix)
Plasminogen, Human-tmvh (Ryplazim) IV Infusion
Platelet-Derived Growth Factors and Platelet-Rich Plasma
Plerixafor (Mozobil) Injection
Plugs for Fistula Repair
Pneumatic Compression Devices
Polatuzumab vedotin-piiq (Polivy) Infusion
Pomalidomide (Pomalyst) Capsule
Ponatinib (Iclusig) Tablets
Ponesimod (Ponvory) Tablet
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
Pozelimab-bbfg (Veopoz)
Pralatrexate (Folotyn) IV
Preventive Services
Private Duty Nursing Care in the Home
Prophylactic Mastectomy
Prosthetic Eyes and Lens Implants
Prosthetics
Protein C Concentrate, human (Ceprotin) Injection
ProThelial for the Treatment of Oral Mucositis
Proton Beam Therapy
Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)
Pulmonary Hypertension Drug Therapy
Pyridoxine HCl Injection (vitamin B-6)
Pyrimethamine (Daraprim)
Quantitative Sensory Testing
Radiofrequency Ablation of Solid Tumors Other Than Liver Tumors
Radiofrequency and Microwave Ablation of Liver Tumors
Radium Ra 223 (Xofigo) Injection
Ramucirumab (Cyramza) Injection
Rasburicase (Elitek)
Ravulizumab (Ultomiris) IV or Subcutaneous
Reconstructive Surgery/ Cosmetic Surgery
Reduction Mammoplasty
Regorafenib (Stivarga) Tablets
Remdesivir (Veklury)
Reslizumab (Cinqair) IV infusion
Resmetirom (Rezdiffra) tablets
Ribociclib (Kisqali)
Rilonacept (Arcalyst) Injection
Riluzole (Tiglutik, Exservan)
Risankizumab-rzaa (Skyrizi) Injectionand Infusion
Risdiplam (Evrysdi)
Ritlecitinib (Litfulo) Capsule
Rituximab Products
Romiplostim Injection (Nplate)
Romosozumab-aqqg (Evenity)
Ropeginterferon alfa-2b-njft (Besremi)
Rozanolixizumab-noli (Rystiggo) Injection
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 (COVID-19) Testing
SARS-CoV-2 Monoclonal Antibodies
Satralizumab (Enspryng)
Scanning Computerized Ophthalmic Diagnostic Imaging
Scintimammography and Gamma Imaging of the Breast
Secukinumab (Cosentyx) Injection and Infusion
Selective Internal Radiation Therapy
Selinexor (Xpovio) Tablet
Setmelanotide (Imcivree) Injection
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 Phenylbutyrate (Buphenyl, Olpruva, and Pheburane)
Sodium phenylbutyrate-taurursodiol (Relyvrio) for oral suspension
Somatic Biomarker Testing (KRAS, NRAS, BRAF, HER2), Including Liquid Biopsy and MicroRNA Expression Testing, in Metastatic Colorectal Cancer
Sonidegib (Odomzo) Capsule
Sorafenib (Nexavar) Tablets
Sparsentan (Filspari)
Speech Generating Devices
Speech Therapy Services
Spesolimab-sbzo (Spevigo) Subcutaneous Injection and Intravenous Infusion
Spinal Cord and Dorsal Root Ganglion Stimulation
Step Therapy Requirements for Medicare Outpatient (Part B) Medications
Stereotactic Body Radiotherapy
Stereotactic Radiosurgery (Intracranial)
Subtalar Arthroereisis
Sunitinib Malate (Sutent) Capsules
Surgical Treatment of Occipital Neuralgia and Headache
Surgical Treatments for Lymphedema and Lipedema
Sutimlimab-jome (Enjaymo) Injection
Tafamidis (Vyndamax, Vyndaqel) Oral
Tafasitamab-cxix (Monjuvi) IV Infusion
Talazoparib (Talzenna)
Talquetamab-tgvs (Talvey) Subcutaneous Injection
Tasimelteon (Hetlioz) Capsules
Tebentafusp-tebn (Kimmtrak) IV Infusion
Technologies for the Evaluation of Malignant Melanoma
Teclistamab (Tecvayli) Injection
Teduglutide (rDNA origin)(Gattex) Injection
Temozolomide (Temodar) Capsule and Injection
Temporary Prostatic Urethral Stents (Including Implantable Nitinol Devices) and Prostatic Urethral Lift
Temsirolimus (Torisel) Injection
Teplizumab (Tzield) Injection
Teprotumumab (Tepezza) Infusion
Teriparatide (Forteo)
Tesamorelin (Egrifta) Injection
Tetrabenazine (Xenazine) and Deutetrabenazine (Austedo, Austedo XR)
Tezacaftor-Ivacaftor (Symdeko)
Tezepelumab-ekko (Tezspire)
Thalidomide (Thalomid) Capsules
Thiamine HCl Injection (vitamin B-1)
Thoracic and Lumbar Spine Surgery
Thoracic Electrical Bioimpedance (TEB)
Thumb Basal Joint Arthroscopy
Tildrakizumab-asmn (Ilumya)
Tiopronin (Thiola, Thiola EC) Tablet
Tisagenlecleucel (Kymriah) Infusion
Tocilizumab (Actemra) Injection and Infusion, Tocilizumab-aazg (Tyenne) Injection and Infusion, and Tocilizumab-bavi (Tofidence) Infusion
Tofacitinib (Xeljanz, Xeljanz XR) Oral Solution, Tablet and Extended-Release Tablet
Tofersen (Qalsody) Intrathecal Injection
Tolvaptan (Jynarque) Tablet
Tolvaptan (Samscaâ„¢) Oral
Topotecan HCl (Hycamtin) Injection and Capsule
Total Ankle Replacement
Total Artificial Hearts and Implantable Ventricular Assist Devices
Total Body Plethysmography
Tralokinumab-ldrm (Adbry) Injection
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
Transurethral Waterjet Ablation of the Prostate
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
Trigger Point Injections
Triheptanoin (Dojolvi) Oral Liquid
Trilaciclib (Cosela) IV infusion
Trofinetide (Daybue) Oral Solution
Tumor Genetic Markers
Tumor Treating Fields Therapy
Ublituximab-xiiy (Briumvi)
Ultrasound in Maternity Care
Ultrasound Osteogenesis Stimulators, Non-invasive
Unclassified Codes and Compounded Drug Products
Unicondylar Interpositional Spacer Devices
Upadacitinib Tablet (Rinvoq) and Oral Solution (Rinvoq LQ)
Ustekinumab (Stelara) Injection and Infusion
Vadadustat (Vafseo)
Vagus Nerve Stimulation
Valbenazine (Ingrezza)
Valoctocogene Roxaparvovec-rvox (Roctavian)
Vamorolone (Agamree) Oral Solution
Vandetanib (Caprelsa) Tablets
Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization
Vedolizumab (Entyvio) Injection and Infusion
Velmanase alfa-tycv (Lamzede) intravenous infusion
Vemurafenib (Zelboraf)
Venetoclax (Venclexta) Tablet
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
Voclosporin (Lupkynis)
Voretigene Neparvovec-rzyl (Luxturna) Injection
Vorinostat (Zolinza) Capsules
Vosoritide (Voxzogo)
Voxelotor (Oxbryta)
Vutrisiran (Amvuttra)
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 (CSAP)
Wireless Capsule Endoscopy
Zanubrutinib (Brukinsa)
Zilucoplan (Zilbrysq) Subcutaneous Injection
Ziv-aflibercept (Zaltrap) IV
Zuranolone (Zurzuvae) Oral Capsules
Certificate of Medical Necessity
Medical Records Fax Coversheet
Bone Marrow Stem Cell Transplant CMN
Solid Organ Transplant CMN
This browser does not support PDFs. Please download the PDF to view it:
Download PDF
.
Private Property of Florida Blue. This payment policy is Copyright 2016, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of Florida Blue. The medical codes referenced in this document may be proprietary and owned by others. Florida Blue makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.
© 2018 Blue Cross and Blue Shield of Florida, Inc. DBA Florida Blue. All rights reserved.