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Medical Guidelines - Alphabetical Index

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A   top

Abatacept (Orencia®)
Abdominoplasty, Panniculectomy and Lipectomy
Ablation Procedures for Peripheral Neuromas
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy)
Acute and Maintenance Tocolysis
Adaptive Behavioral Treatment for Autism Spectrum Disorders
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies
Allergy Immunotherapy (Desensitization)
Allergy Testing
Allogeneic Hematopoietic Transplant for Genetic Diseases
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
Alemtuzumab (LemtradaTM)
Ambulance and Medical Transport Services
Ambulatory Event Monitors
Amniotic Membrane and Amniotic Fluid Injections
Analysis of MGMT Promoter Methylation in Malignant Gliomas
Anesthesia Services
Antiemetic Injection Therapy
Antiprothrombin Antibody Testing
Aqueous Shunts and Devices for Glaucoma
Artificial Intervertebral Disc
Artificial Pancreas Device Systems
Assays of Genetic Expression to Determine Prognosis of Breast Cancer
Atezolizumab (Tecentriq) for Intravenous Use
Autografts and Allografts in the Treatment of Focal Articular Cartilage
Autologous Chondrocyte Implantation
Automated Percutaneous and Endoscopic Discectomy
Axial Lumbosacral Interbody Fusion

B   top

Baroreflex Stimulation Devices
Belimumab (Benlysta)
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer's Disease
Bevacizumab in Advanced Adenocarcinoma of the Pancreas
Bioengineered Skin and Tissue
Biofeedback as a Treatment of Pain
Bioimpedance Devices for Detection of Lymphedema
Bone Mineral Density Studies
Bone Morphogenetic Protein
Botulinum Toxin Injection
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer
Brachytherapy Treatment of Breast Cancer
BRAF Gene Mutation Testing to Select Melanoma or Glioma Patients for Targeted Therapy
Breast Surgeries
Brentuximab Vedotin (Adcetris)
Bronchial Thermoplasty
Buprenorphine Implant for Treatment of Opioid Dependence

C   top

Cabazitaxel (Jevtana)
Capsule Endoscopy, Wireless
CAR-T Therapy
Cardiac (Heart) Transplantation
Cardiac Hemodynamic Monitoring in the Outpatient Setting
Cardiovascular Disease Risk Tests
Carfilzomib (Kyprolis®)
Carotid Artery Angioplasty / Stenting (CAS)
Carotid Intimal-Medial Thickness
Carrier Screening for Genetic Disease
Catheter Ablation as a Treatment for Atrial Fibrillation
Cellular Immunotherapy for Prostate Cancer
Charged Particle Radiotherapy
Chelation Therapy
Chemoembolization of the Hepatic Artery, Transcatheter Approach
Chemotherapy For Malignant Disease
Children's Mobility and Positioning Equipment
Chiropractic Services
Chromoendoscopy as an Adjunct to Colonoscopy
Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss
Circulating Tumor DNA for Cancer Management (Liquid Biopsy)
Clinical Trial Services
Cochlear Implant
Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer
Complementary and Alternative Medicine
Composite Allotransplantation of the Hand and Face
Computed Tomography to Detect Coronary Artery Calcification
Computer-Aided Evaluation of Malignancy with MRI of the Breast
Computer Assisted Surgical Navigational Orthopedic Procedures
Computerized Corneal Topography
Confocal Laser Endomicroscopy
Congenital Heart Defect, Repair Devices
Continuous Monitoring of Glucose in the Interstitial Fluid
Continuous Passive Motion in the Home Setting
Convection-Enhanced Delivery of Therapeutic Agents to the Brain
Cord Blood as a Source of Stem Cells
Corneal Collagen Cross-linking
Cosmetic and Reconstructive Surgery
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
CT Perfusion Imaging of the Brain

D   top

Daratumumab (Darzalex)
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
Denosumab (ProliaTM, XGEVATM)
Dental Inpatient and Outpatient Services
Dental, Reconstructive Services
Dermatologic Applications of Photodynamic Therapy
Diagnosis and Treatment of Sacroiliac Joint Pain
DNA Based Testing for Adolescent Idiopathic Scoliosis
Documentation Requirements for Treatment of End Stage Renal Disease
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
Drug Testing in Pain Management and Substance Abuse Treatment
Dry Needling of Myofascial Trigger Points
Durable Medical Equipment (DME)
Dynamic Posturography

E   top

Eculizumab (Soliris®)
Edaravone (RadicavaTM)
Electrical Bone Growth Stimulation
Electrical Stimulation for the Treatment of Arthritis
Electrodiagnostic Studies
Electrogastrography, Cutaneous
Electromagnetic Navigation Bronchoscopy
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Electrostimulation and Electromagnetic Therapy for Wounds
Elotuzumab (Empliciti)
Endobronchial Valves
Endothelial Keratoplasty
Endovascular Procedures for Intracranial Arterial Disease
Endovascular Therapies for Extracranial Vertebral Artery Disease
Enhanced External Counterpulsation (EECP)
Enteral Nutrition
Enzyme Replacement Therapy for Lysosomal Storage Disorders
Epidural Steroid Injections for Back Pain
Epiretinal Radiation Therapy for Age-Related Macular Degeneration
Eribulin Mesylate (Halaven)
Erythropoiesis-Stimulating Agents (ESAs)
Esophageal pH Monitoring
Eteplirsen for Duchenne Muscular Dystrophy
Exhaled Nitric Oxide Measurement
External Defibrillators
Extracorporeal Photopheresis
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

F   top

Facet Joint Denervation
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Calprotectin Test
Fecal Microbiota Transplantation
Fetal RHD Genotyping Using Cell-Free Fetal DNA
Focal Treaments for Prostate Cancer
Functional Capacity Assessment and Work Hardening
Fundus Photography

G   top

Gastric Electrical Stimulation
Gastroesophageal Reflux Disease, Transendoscopic Therapies
Gender Confirmation Surgery and Hormone Therapy
Gene Expression Profiling for Uveal Melanoma
Gene Expression Testing in the Evaluation of Patients With Stable Ischemic Heart Disease
General Approach to Evaluating the Utility of Genetic Panels
General Approach to Genetic Testing
Genetic and Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
Genetic Testing for Alpha-1 Antitrypsin Deficiency
Genetic Testing for Alpha Thalassemia
Genetic Testing for Alzheimer's Disease
Genetic Testing for Breast and Ovarian Cancer
Genetic Testing for CADASIL Syndrome
Genetic Testing for Cardiac Ion Channelopathies
Genetic Testing for Colon Cancer
Genetic Testing for Cutaneous Malignant Melanoma
Genetic Testing for Dilated Cardiomyopathy
Genetic Testing for Duchenne and Becker Muscular Dystrophy
Genetic Testing for Epilepsy
Genetic Testing for Evaluation of Developmental Delay/Autism Spectrum Disorder
Genetic Testing for Fanconi Anemia
Genetic Testing for FLT3, NPM1 and CEBPA Mutations in Acute Myeloid Leukemia
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome
Genetic Testing for Hereditary Hearing Loss
Genetic Testing for Hereditary Hemochromatosis
Genetic Testing for Hereditary Pancreatitis
Genetic Testing for Heterozygous Familial Hypercholesterolemia
Genetic Testing for Lactase Insufficiency
Genetic Testing for Macular Degeneration
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
Genetic Testing for Myeloproliferative Neoplasms
Genetic Testing for Neurofibromatosis
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic Testing for PTEN Hamartoma Tumor Syndrome
Genetic Testing for Rett Syndrome
Genetic Testing for Statin-induced Myopathy
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathy
Glaucoma, Evaluation by Ophthalmologic Techniques
Golimumab (Simponi Aria)
Goserelin Acetate (Zoladex)
Growth Factors in Wound Healing
Guidelines for Global Maternity Reimbursement

H   top

Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery
Heart-Lung Transplantation
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
Hematopoietic Cell Transplantation for CLL and SLL
Hematopoietic Cell Transplantation for Hodgkin Lymphoma
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
Hematopoietic Stem-Cell Transplant for Non Hodgkin's Lymphomas
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia
Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
Hemodialysis Treatment for ESRD
Hormone Pellet Implantation for Treatment of Menopause Related Symptoms
Hyperbaric Oxygen Therapy
Hyperhidrosis, Treatment of
Hyperthemic Intraperitoneal Chemotherapy

I   top

Identification of Microorganisms Using Nucleic Acid Probes
Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis
Immune Cell Function Assay
Immunoglobulin Therapy
Implantable Bone Conduction Hearing Aids
Implantable Cardioverter Defibrillator
Implantation of Intrastromal Corneal Ring Segments
Infertility, Diagnosis and Treatment
Infliximab (Remicade)
Infusion Therapy in the Home
Ingestible pH and Pressure Capsule
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Injectable Clostridial Collagenase for Fibroproliferative Disorders
Inotuzumab (Besponsa)
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT)
Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities
Intensity Modulated Radiation Therapy (IMRT) for Tumors of the Central Nervous System
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck
Intensity Modulated Radiation Therapy (IMRT) of the Chest
Intensity Modulated Radiation Therapy (IMRT) of the Prostate
Interferential Stimulation
Interleukin-5 Antagonists
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Interspinous Fixation (Fusion) Devices
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee
Intracellular Micronutrient Analysis
Intradialytic Parenteral Nutrition
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)
Intrauterine Ablation or Resection of the Endometrium
Intravenous Anesthetics for the Treatment of Chronic Pain
Intravenous Antibiotic Therapy for Lyme Disease
Intravitreal Implant
Invasive Prenatal (Fetal) Diagnostic Testing
Investigational (Experimental) Services
In Vitro Chemoresistance and Chemosensitivity Assays
Ipilimumab (Yervoy)
Islet Cell Transplantation

J   top


K   top


L   top

Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer
Laboratory Tests for Heart Transplant Rejection
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
Laser Treatment of Onychomycosis
Laser Treatment of Port Wine Stains
Light Therapy for Dermatologic Conditions
Lipid Apheresis
Liver Transplant
Lumbar Spine Fusion Surgery
Lung and Lobar Lung Transplantation
Lung Volume Reduction Surgery
Lysis of Epidural Adhesions

M   top

Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD)
Magnetic Resonance Imaging (MRI) Targeted Biopsy of the Prostate
Magnetic Resonance Spectroscopy
Magnetoencephalography/Magnetic Source Imaging
Maternal and Fetal Diagnostics
Measurement of Serum Antibodies to Infliximab and Adalimumab
Medical Necessity
Melphalan Hydrochloride (Evomela) for Intravenous Use
Meniscal Allografts and Other Meniscal Implants
Microarray based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification
Microarray based Gene Expression Testing for Cancers of Unknown Primary
Microprocessor-Controlled Prostheses for the Lower Limb
Microwave Tumor Ablation
Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Risk
Mohs' Micrographic Surgery
Molecular Analysis for Targeted Therapy for Non-Small Cell Lung Cancer (NSCLC)
Molecular Markers in Fine Needle Aspirates of the Thyroid
Molecular Panel Testing of Cancers to Identify Targeted Therapies
Molecular Testing in the Management of Pulmonary Nodules
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting
Monoclonal Antibody Imaging for Prostate Cancer
MRI-Guided Focused Ultrasound (MRgFUS)
MRI-Guided Laser-induced Thermotherapy for Neurological Indications
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
Myocardial Sympathetic Innervation Imaging
Myoelectric Prosthetic Components for the Upper Limb

N   top

Natalizumab (Tysabri)
Navigated Transcranial Magnetic Stimulation (nTMS)
Necitumumab (Portrazza)
Nerve Fiber Density Testing
Neural Therapy
Neurostimulation, Electrical
New-To-Market Specialty Drug PPA Requirements
Non Contact Ultrasound Treatment for Wounds
Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA
Noninvasive Fractional Flow Reserve Using Computed Tomography Angiography
Noninvasive Prenatal Testing for Fetal Aneuploidies Using Cell-Free Fetal DNA
Noninvasive Respiratory Assist Devices
Non Pharmacologic Treatment of Rosacea
Nusinersen (SpinrazaTM)
Nutrient/Nutritional Panel Testing

O   top

Observation Room Services
Occipital Nerve Stimulation
Ocrelizumab (OcrevusTM)
Optical Coherence Tomography (OCT) Anterior Segment of the Eye
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
Orthodontics for Pediatric Patients
Orthognathic Surgery
Orthopedic Applications of Stem Cell Therapy
Oscillatory Devices for the Treatment of Respiratory Conditions
Outpatient Code Editor (OCE) Edits
Ovarian and Internal Iliac Vein Embolization

P   top

Paclitaxel (Abraxane)®
Pancreas Transplant
Paraspinal Surface Electromyography (SEMG)
PathFinder TG Molecular Testing
Patient Lifts
Patient-Specific Cutting Guides and Custom Knee Implants
PD-1 Inhibitors
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Pemetrexed (Alimta)
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention
Peripheral Arterial Tonometry (PAT)
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction
Pertuzumab for Treatment of Malignancies
Pharmacogenetic Testing for Drug Metabolism
Place of Service for Medical Infusions
Plugs for Fistula Repair
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Polysomnography for Non-Respiratory Sleep Disorders
Positional Magnetic Resonance Imaging (MRI)
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
Pressure Reducing Support Surfaces
Private Duty Nursing Services
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
Progesterone Therapy in High Risk Pregnancies
Prostatic Urethral Lift
Proteogenomic Testing for Patients with Cancer (GPS CancerTM Test)
Proteomics-based Testing Related to Ovarian Cancer
Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer
Pulmonary Hypertension, Drug Management

Q   top

Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder

R   top

Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension
Radiosurgery, Stereotactic Approach
Reconstructive Eyelid Surgery and Brow Lift
Refractive Surgery
Rehabilitative Therapies
Renal (Kidney) Transplantation
Repository Corticotropin (H.P. Acthar Gel)
Residential Treatment
Respiratory Syncytial Virus Prophylaxis
Retinal Prosthesis
Rituximab for the Treatment of Rheumatoid Arthritis
Romiplostim (NPlate)

S   top

Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction
Sacroiliac Joint Fusion
Salivary Hormone Tests
Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA)
Semi Implantable and Fully Implantable Middle Ear Hearing Aid
Sensory Integration Therapy
Serum Biomarker Human Epididymis Protein 4 (HE4)
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus
Signal Averaged ECG
Siltuximab (Sylvant)
Skilled Nursing Facility Care
Skilled Nursing Services
Sleep Apnea: Diagnosis and Medical Management
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant
Somatostatin Analogs
Speech Generating Devices
Spinal Cord Stimulation
Spinal Manipulation under Anesthesia
ST2 Assay for Chronic Heart Failure
Stem-cell Therapy for Peripheral Arterial Disease
Sphenopalatine Ganglion Block for Headache
Subtalar Arthroereisis
Surgery for Femoroacetabular Impingement
Surgery for Groin Pain in Athletes
Surgery for Morbid Obesity
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome
Surgical Deactivation of Headache Trigger Sites
Surgical Management of Transcatheter Heart Valves
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)
Surgical Treatment of Sinus Disease
Surgical Ventricular Restoration

T   top

Talimogene Laherparepvec (ImlygicTM)
Temporomandibular Joint Dysfunction (TMJD)
Testing Serum Vitamin D Levels
Testosterone Pellet Implantation for Androgen Deficiency
TENS (Transcutaneous Electrical Nerve Stimulator)
Tinnitus Treatment
Tocilizumab (Actemra)
Topical Negative Pressure Therapy for Wounds
Topotecan Hydrochloride (Hycamtin)
Total Facet Arthroplasty
Transanal Endoscopic Microsurgery
Transanal Radiofrequency Treatment of Fecal Incontinence
Transcatheter Closure of Ventricular Septal Defects
Transtympanic Micropressure Applicationsas a Treatment of Meniere's Disease
Treatment of Hereditary Angioedema
Treatment for Severe Primary IGF-1 Deficiency
Tumor-Treatment Fields Therapy for Glioblastoma

U   top

Ultrasound Accelerated Fracture Healing Device
Ultraviolet Light Therapy in the Home Setting(UVB)
Urinary Tumor Markers for Bladder Cancer
Ustekinumab (Stelara)

V   top

Vagus Nerve Stimulation
Varicose Veins, Treatment for
Vectra® DA Blood Test for Rheumatoid Arthritis
Vedolizumab (Entyvio)
Vertebral Axial Decompression (VAX-D)
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents
Vestibular Function Testing
Viscocanalostomy and Canaloplasty

W   top

Wheelchairs (Manual and Power Operated)
White Blood Cell Growth Factors
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

X   top

Xolair (Omalizumab)

Y   top


Z   top

Zinplava (bezlotoxumab)



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