BlueCross BlueShield of Tennessee Medical Policy Manual

Pediatrics

• Cranial Orthosis for the Treatment of Plagiocephaly

• Extracorporeal Membrane Oxygenation (ECMO)

• Home Phototherapy for Neonatal Jaundice

• Infant Home Apnea Monitoring

• Intrauterine Laser Ablation of Placental Vessels for Twin-to-Twin Transfusion Syndrome (TTTS)

• Nutritional Treatment of Inborn Errors of Metabolism

• Ocular Photoscreening in the Primary Care Physician's Office as a Screening Tool to Detect Amblyogenic Factors

• Phenylketonuria (PKU) Formula

• Rotavirus Vaccine

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