BlueCross BlueShield of Tennessee Medical Policy Manual

DME (Durable Medical Equipment)

• Actigraphy for Sleep Disorders

• Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

• Arthroereisis Implant for the Treatment of Flexible Flatfoot Conditions

• Artificial Liver Assist Devices for the Treatment of Liver Conditions

• Baroreflex Stimulation Devices

• Cervical Traction Devices for Home Use

• Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion Pump

• Continuous Passive Motion (CPM) Device in the Home Setting

• Cooling Devices Used in the Outpatient Setting

• Daily Hemodialysis in the Home

• End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease

• Endobronchial Valves

• Enuresis Alarms

• External Penile Vacuum Constriction Devices

• Home Apnea Monitoring / Home Cardiorespiratory Monitoring

• Home Hyperalimentation (Total Parenteral/Enteral Nutrition)

• Home Pulse Oximetry

• Home Spirometry

• Ingestible pH and Pressure Capsule

• Intradialytic Parenteral Nutrition

• Intraoral Devices for the Treatment of Headaches

• Laser Device for Obtaining Blood Sample

• Light Box Therapy (Phototherapy) for Seasonal Affective Disorder

• Light Emitting Diode (LED) Therapy

• Lymphedema Devices

• Mechanical In-Exsufflator (Cough Machine)

• Mechanical Stretch Devices for the Treatment of Joint Stiffness

• Microprocessor-Controlled Prostheses for the Lower Limb

• Myoelectric Prosthetic Components for the Upper Limb

• Nebulizer Use in Home (Adult & Pediatric)

• Negative Pressure Wound Therapy in the Outpatient Setting

• Non-Invasive Medical Devices for Measuring Arterial Elasticity for Cardiovascular Disease

• Noncontact Radiant Heat Wound Therapy Systems

• Oral Appliances for Management of Mild to Moderate Obstructive Sleep Apnea (OSA)

• Orthotics

• Pelvic Floor Stimulation

• Percussion / Oscillating Devices for the Treatment of Respiratory Conditions

• Percutaneous Electrical Nerve Stimulation (PENS)

• Retinal Prosthesis

• Short-Term and Long-Term Continuous Glucose Monitoring of the Interstitial Fluid

• Spinal Unloading Devices for the Treatment of Low Back Pain

• Tinnitus Retraining Therapy (TRT) and Tinnitus Maskers for the Treatment of Tinnitus

• Transcatheter Closure Devices for Cardiac Defects

• Transcutaneous Electrical Nerve Stimulation (TENS)

• Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting

• Transtympanic Micropressure Applications as a Treatment of Ménière's Disease

• Ultrasound Accelerated Fracture Healing Device

• Ventricular Assist Devices

• Wearable Cardioverter Defibrillator for the Prevention of Sudden Death

• Wireless Pressure Sensors in Endovascular Aneurysm Repair

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