BlueCross BlueShield of Tennessee Medical Policy Manual

Musculoskeletal

• Abatacept

• Allograft Anterior Cruciate Ligament (ACL) Reconstruction

• Arthroereisis Implant for the Treatment of Flexible Flatfoot Conditions

• Artificial Intervertebral Disc

• Autologous Chondrocyte Implantation (ACI)

• Bone Lengthening for Congenital Conditions, Limb Discrepancies and Angular Deformities of Long Bones

• Cervical Traction Devices for Home Use

• Collagen Cross Links as Markers of Bone Turnover

• Computer Assisted Surgical Navigational Orthopedic Procedures

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

• Cooling Devices Used in the Outpatient Setting

• Denosumab

• Dynamic Spinal Visualization

• Electrical Bone Growth Stimulation

• Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions

• Facet Arthroplasty

• Hyaluronan Derivatives

• Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

• Infliximab - Injectable

• Interspinous Distraction Devices (Spacers)

• Intradiscal Annuloplasty for the Treatment of Discogenic Back Pain

• Intraoperative Neurophysiologic Monitoring

• Lumbar Epidural Steroid Injections for Treatment of Low Back Pain

• Lumbar Facet Steroid Injections for Treatment of Low Back Pain

• Lysis of Epidural Adhesions for Chronic Pain Syndrome

• Manipulation of Musculoskeletal System Under Anesthesia

• Mechanized Axial Spinal Distraction Therapy Devices

• Meniscal Allografts and Collagen Meniscus Implants

• Mentoplasty (Chin Augmentation, Genioplasty)

• Microprocessor-Controlled Prostheses for the Lower Limb

• Modified Condylotomy for Treatment of Temporomandibular Joint (TMJ) Disorders

• Myoelectric Prosthetic Components for the Upper Limb

• Orthognathic Surgery

• Osteochondral Allografting

• Osteochondral Autografting (OCG)

• Percutaneous Disc Decompression Using Low-Temperature, Localized, Radiofrequency Energy

• Percutaneous Discectomy

• Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

• Piezoelectric Sensor Analysis and Oscillating Force Delivered Vertebral Adjustment in the Evaluation and Treatment of the Spinal Column

• Prolotherapy for Musculoskeletal Disorders

• Reverse Shoulder Arthroplasty

• Sacroiliac Joint Arthrography and Injection

• Shoulder Resurfacing

• Spinal Unloading Devices for the Treatment of Low Back Pain

• Temporomandibular Joint (TMJ) Arthroscopy

• Thermal Shrinkage as a Treatment of Joint Instability

• Total Ankle Replacement

• Total Hip Resurfacing

• Ultrasound Accelerated Fracture Healing Device

• Unicompartmental Knee Replacement

• Unicondylar Interpositional Spacer for the Treatment of Osteoarthritis

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