“BCBST
UM Guidelines
Musculoskeletal

Listed by Conditions


Achilles Tendon Repair

Acromioplasty and Rotator Cuff Repair

Ankle Dislocation, Closed or Open Reduction

Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF)

Arthrography, MR

Cervical Fusion, Anterior

Chiropractic Manipulation

Elbow Fracture, Open Treatment

Femur Fracture, Removal of Internal Fixation Device

Foot Fracture, Calcaneus or Talus, Open Reduction, Internal Fixation (ORIF)

Humerus Fracture, Closed or Open Reduction

Knee Arthrotomy

Knee: Fracture of Tibial Plateau, Closed or Open Reduction

Knee: Patella Reconstruction or Realignment for Recurrent Dislocation

Lumbar Diskectomy, Foraminotomy, or Laminotomy

Lumbar Laminectomy

Slipped Upper Femoral Epiphysis, Closed Reduction

Spinal Manipulation Therapy (SMT), Chiropractic and Other

Tibia/Fibula Shaft Fracture, Closed or Open Reduction

Tibial Osteotomy, Adult

Vertebroplasty and Kyphoplasty

Wrist Arthroplasty

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