BlueCross BlueShield of Tennessee
Medical Policy Manual
Master Index

A / B / C / D / E / F / G / H / I / J / K / L / M / N / O / P / Q / R / S / T / U / V / W / X / Y / Z

A

 

Abatacept

Abecma®

Abbreviated Daytime Sleep Study (e.g. PAP-NAP)

Ablation for Nasal Obstruction and Rhinitis, RF
Ablation Procedure for Peripheral Neuromas

AbobotulinumtoxinA

Absorbable Nasal Implant for the Treatment of Nasal Valve Collapse

Acclarent Balloon Sinuplasty™

Acoustic Rhinometry

Actemra®

Acthar® Gel - H.P.

Actigraphy

Acupuncture

Adakveo

ADAMTS13, recombinant-krhn

Adcetris®

Adhesiolysis, Epidural for Chronic Pain Syndrome

Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

Ado-Trastuzumab Emtansine

Adoptive Immunotherapy
Adstiladrin®
Aducanumab-avwa
Aduhelm™
Adzynma
Afamitresgene Autoleucel
Aflibercept (Eylea®; Eylea®HD)
Agalsidase Beta

Aldesleukin

Aldurazyme®

Alemtuzumab

Alglucosidase Alfa

Allergy Testing,

AlloDerm®

Allograft Transplantation, Meniscal

Allografting, Osteochondral
Allogeneic Processed Thymus Tissue-agdc
Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin®-C, Zemaira®)
Alternative Medicine

Amivantamab-vmjw

Amniotic Membrane and Amniotic Fluid Injections

Amondys 45™

Amtagvi

Amvuttra™

AmpliChip CYP450 Test

Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Angioplasty or Stenting for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

Anifrolumab-fnia

Ankle - Total Replacement

Anktiva®

Antigens, Ovarian-Tumor Assoc. Assay

Aphexda™

Apligraf®

Aqueous Shunts and Stents for Glaucoma

Aranesp®

Arranon®

Art-Assist Device™

Arthroereisis Implant for the Treatment of Flexible Flatfoot Conditions

Arthrography, Sacroiliac Joint

Artificial Intervertebral Disc

Asparaginase Erwinia chrysanthemi (recombinant)-rywn (Rylaze™) (Intramuscular)

Asparlas™

Atezolizumab

Atezolizumab and Hyaluronidase-tqjs 

Atidarsagene Autotemcel

Avacincaptad Pegol

Aucatzyl®

Auditory Integration Therapies

Auricular Electrostimulation

Autologous Chondrocyte Implantation (ACI)

Autologous Fat Grafting to the Breast

Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas

Autolymphocyte Therapy (ALT)

Automated Percutaneous and Endoscopic Discectomy

Autonomic Nervous System Testing
Avalglucosidase Alfa-ngpt

Avelumab

Axatilimab-csfr

Axial Lumbosacral Interbody Fusion

Axicabtagene Ciloleucel

Azacitidine

 

B

 

Balloon and Self-Expanding Absorptive Ostial Dilation for Treatment of Rhinosinusitis

Balloon Dilation of the Eustachian Tube

Baroreflex Stimulation Devices

Bavencio®

Beleodaq®

Belimumab

Belinostat

Bendamustine Products (Treanda®, Belrapzo®, Bendeka®, Vivimusta™, Bendamustine)

Benlysta®

Benralizumab

Beovu®

Beqvez™

Berinert®

Beremagene Geperpavec-svdt

Besponsa®

Betibeglogene autotemcel

Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™; Avzivi®)

Bioelectrical Impedance Spectroscopy

Bioengineered Skin and Soft Tissue Substitutes

Biofeedback and Neurofeedback

Bioidentical Compounded Hormone Therapy

Bioimpedance - Thoracic Electrical

Bioimpedance Devices for Detection of Lymphedema

Biological Therapy / Biotherapy

Biomarker Human Epididymis Protein 4 (HE4)

Biosynthetic Fistula Plugs

Bizengri®

Blinatumomab

Blincyto®

Bortezomib (Velcade®, Bortezomib)

Botulinum Toxin (Botox®)

Brachytherapy for Non-Melanoma Skin Cancer

Breast Augmentation / Mammaplasty (Non-Cancerous)

Breast Cancer Gene Expression Assays

Breast Cancer IndexSM

Breast Implant Removal

Breast Reconstructive and Symmetry Surgery Following Mastectomy

Breast Tomosynthesis, Digital

Breathmeter

Brentuximab Vedotin

Brexucabtagene Autoleucel

Breyanzi®

Brineura®

Briumvi™

Brolucizumab-dbll

Bronchial Drainage System (Vest)

Browplasty

Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR) and Incontinence

Burosumab-twza

 

C

 

C1 Esterase Inhibitor (Berinert®)

C1 Esterase Inhibitor (Cinryze®)

C1 Esterase Inhibitor (Ruconest®)

C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda®)

CA-125 Assay
Cabazitaxel (Jevtana®; Cabazitaxel)
Calaspargase Pegol-mknl
Canakinumab

Cancer Tumor Markers, Ovarian

Carbogen (95% Oxygen, 5% Carbon Dioxide) Inhalation in Cancer Treatment

Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

Cardioverter Defibrillator, Wearable

Carfilzomib

Carimune® NF

Carotid Intima-Medial Thickness (CIMT), Ultrasonographic Measurements as an Assessment of Subclinical Atherosclerosis

Casgevy™

Carvyktil

Cemiplimab-rwlc

Central Nervous System Embryonal and Ependymoma Tumors - HSCT

Cerezyme®

Cerliponase Alfa

Certolizumab Pegol

Cervical Traction Devices for Home Use

Cetuximab

CHARGE Syndrome - Genetic Testing

CHEK2 - Genetic Testing

Chelation Therapy

Chemical Endarterectomy

Chemoembolization for the Treatment of Surgically Unresectable Hepatocellular Carcinoma

Chin Augmentation (Mentoplasty, Genioplasty)

Chondrocyte Implantation (ACI), Autologous

Chromosomal Microarray Analysis for Evaluation of Pregnancy Loss

Chronic Intermittent Intravenous Insulin Therapy

Ciltacabtagene Autoleucel

Cimzia®

Cineradiography

 

Cinqair®

 

Cinryze®

 

Cipaglucosidase Alfa-atga7

 

Circulator Boot System

Coblation Technology

Collagen Cross-Linking

Collagen Implantation for Urinary Incontinence

Collagen Meniscus Implants

Collagenase

Columvi™

Complementary and Alternative Medicine

Composite Tissue Allotransplantation

Compounded Hormone Therapy - Bioidentical

Computed Tomography Angiography for Coronary Artery Evaluation

Computer Assisted Surgical Navigation for Orthopedic Procedures

Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease

Confocal Laser Endomicroscopy

Conjunctival Challenge Test

Continuous Home Pulse Oximetry

Continuous Passive Motion (CPM) Device in the Home Setting

Corneal Collagen Cross-Linking

Coronary Computed Tomography Angiography (CCTA)

CorRestore™ Patch System

Corticotropin-ACTH:[HP Acthar Gel (repository corticotropin injection), Cortrophin® Gel

Cosela™

Cosentyx®

Cranial Electrotherapy Stimulation

Crizanlizumab-tmca

Crovalimab-akkz

Cryosurgical Ablation of Solid Tumors

Crysvita®

Current Perception Threshold Testing

Cutaneous Electrogastrography (EGG)

CYP2D6

Cyramza®

Cytarabine Liposome for Injection

Cytochrome p450 Genotyping

 

D

 

Daily Hemodialysis in the Home

Danyelza®

Daratumumab

Daratumumab and hyaluronidase-fihj

Darbepoetin Alfa

Datopotamab Deruxtecan-dlnk
Datroway®

Daunorubicin and Cytarabine Liposome for Injection

DaxibotulinumtoxinA-lanm

Daxxify™

Defibrillator, Wearable Cardioverter

Deflux®

Degarelix

Delandistrogene moxeparvovec-rokl

Denosumab (Prolia®)

Denosumab (Xgeva®)

Dermagraft®

DEXA or DXA for Vertebral Fracture Assessment

DEXA to Determine Body Composition

Dexamethasone Implant

Diabetes Management

Diagnosis and Treatment of Facet Joint Pain

Diagnosis and Treatment of Sacroiliac Joint Pain

Diagnostic Spinal Ultrasound (Echography/Sonogram), Nonoperative

Digital Breast Tomosynthesis

Digital Health Technologies: Diagnostic Applications

Digital Health Therapies for Attention Deficit/Hyperactivity Disorder (ADHD)

Digital Health Therapies for Substance Use Disorders

Digital Motion X-ray (DMX)

DISC Nucleoplasty™

Discectomy, Percutaneous

Donanemab-azbt

Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem Cell Transplant

Dostarlimab-gxly

Dual X-Ray Absorptiometry for Vertebral Fracture Assessment

Durolane®

Durvalumab

Dynamic Posturography in the Assessment of Balance

Dynamic Spinal Visualization

Dysport®

 

E

 

Ecallantide

Echography,

Eculizumab
Edaravone
Efgartigimod Alfa-fcab (Vyvgart®); Efgartigimod Alfa-fcab and Hyaluronidase-qvfc (Vyvgart®Hytrulo)

Efgartigimod Alfa-fcab and Hyaluronidase-qvfc

Elahere™
Eflapegrastim-xnst
Elapegademase-lvlr
Elaprase®

Electrical Impedance Scanning of the Breast

Electrical Nerve Stimulation,  

Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease

Electrocardiography, Signal Averaged (SAECG)

Electrogastrography (EGG)

Electrolysis, Removal of Hair

Electromagnetic Stimulation for the Treatment of Arthritis

Electromagnetic Therapy for the Treatment of Wound s

Electromyography (EMG), Needle

Electromyography (sEMG), Surface

Electron Beam Computed Tomography (EBCT) -

Electronic Brachytherapy for Non-Melanoma Skin Cancer

Elelyso®

Elevidys®

Elfabrio®

Eligard®

Elivaldogene Autotemcel

Elosulfase Alfa

Elotuzumab
Elranatamab-bcmm
Elrexfio™
Elzonris™
Emapalumab-lzsg

Empliciti™

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

EndoBarrier® Gastrointestinal Liner

EndoCinch™

Endometrial Ablation for Treatment of Menorrhagia

Endomicroscopy - Confocal Laser

EndoPredict

Endoscopic Discectomy

Endothelial Function Assessment

Endothelial Keratoplasty

Enfortumab Vedotin-ejfv
Enhertu®

Enjaymo™

Enteral Nutrition/Home Hyperalimentation

Enteryx™

Entyvio®

Epcoritamab-bysp

Epicel®

Epidural Adhesiolysis

Epidural Steroid Injections for Treatment of Back Pain

Epiretinal Radiation Therapy for Age-Related Macular Degeneration

Epkinly™
Epoetin Alfa Products (Epogen®, Procrit®, Retacrit®)

Epoprostenol for Continuous Intravenous Infusion (Flolan®/ Veletri®)

Eptinezumab-jjmr

Erbitux®

Eribulin Mesylate

EsophyX™

Eteplirsen

Etranacogene Dezaparvovec-drlb

Euflexxa®

Evenity™

Evinacumab-dgnba

Evkeeza

ExAblate 2000

Exagamglogene Autotemcel

Exondys 51™

Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities

Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
External Ear Reconstruction

Extracorporeal Shock Wave Therapy for Wounds

Eyelid Thermal Pulsation

Eylea®; Eylea®HD

 

F

 

Fabrazyme®

Face Transplantation (Composite Tissue Allotransplantation)

Facelift, Facial Thread Lift

Facet Arthroplasty

Facet Joint Injections

Facet Joint Neurotomy

Facet Steroid Injections

Facial Thread Lift

Facioscapulohumeral Muscular Dystrophy, Genetic Testing

Fam-trastumzumab Deruxtecan-nxki

Faricimab-svoa

Fasenra®

Feather Lift

Femoroacetabular Impingement

Fetal Surgery for Prenatally Diagnosed Malformations

Fidanacogene Elaparvovec-dzkt

Firazyr®

Firmagon®

First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment

Fistula Plugs

Fluocinolone Acetonide Implant (Iluvien®)
Fluocinolone Acetonide Implant (Retisert®)
Fluocinolone Acetonide Implant (Yutiq™)

Focal Laser Ablation for Prostate Cancer

Folotyn®

Fosdenopterin

Fractional Laser Treatment of Vulvovaginal Atrophy

Functional Neuromuscular Electrical Stimulation

Fyarro™

 

G

 

Galsulfase

Gamifant™

Gammagard® Liquid (Subcutaneous)

Gammaked® (Subcutaneous)

Gamunex®-C (Subcutaneous)

Gazyva®

Gel-One®

Gel-Syn™

Gemtuzumab Ozogamicin

Gender Reassignment Surgery

Gene Expression Assays - Breast Cancer

Gene Expression Profile Analysis for Prostate Cancer Management

Genecept™ Assay

Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

Genetic Panel Assay for Psychiatric Disorders

Genetic Testing,

Genioplasty (Mentoplasty)

Genotyping - Cytochrome p450

GenVisc® 850

GERD - Transesophageal Endoscopic Therapies

Givlaari™

Givosiran

Glofitamab-gxbm

Glycosylated Hemoglobin A1c Screening

Golimumab for Intravenous Infusion

Golodirsen
Goserelin Acetate
Guselkumab 

 

H

 

H.P. Acthar® Gel

Haegarda®

Hair Removal

Hair Transplantation

Halaven®

Hand Held Oscillatory Positive Expiratory Pressure Devices

Hand and/or Face Transplantation (Composite Tissue Allotransplantation)

Hematopoietic Progenitor Cell (HPC) Boost

Hematopoietic Stem-Cell Transplantation,

Hemodialysis in the Home

Hemoglobin A1c Screening, Glycosylated

Hemgenix®

Herceptin Hylecta™

Hercessi™

High-Frequency Electrical Stimulation Pulses With or Without a Low Dose Local Anesthetic for the Treatment of Pain

Hippotherapy

Histerlin

Home Apnea Monitoring / Home Cardiorespiratory Monitoring

Home Nutritional Support (Total Parenteral/Enteral Nutrition)

Home Pulse Oximetry

Home Spirometry

Hospital-Grade Breast Pump

Human Amniotic Membrane Grafts and Amniotic Fluid Injections

Human Epididymis Protein 4 (HE4)

Hyalgan®

Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synojoynt, Synvisc™, & Synvisc-One™, Triluron™, TriVisc™, VISCO-3™, & Triluron™, sodium hyaluronate 1% (Intra-Articular)

Hymovis®

Hypertension Therapy Using Low Level Electrical Stimulation

 

I

 

Ibalizumab-uiyk

Icatibant

Idecabtageme Vicleucel (Abecma®)

iDose TR®

Idursulfase

IG-MILD for Spinal Stenosis

Ilaris®

Ilumya™

Iluvien®

Image-Guided Minimally Invasive Decompression for Spinal Stenosis

Imdelltra™

Imetelstat

Imfinzi®

Imiglucerase

Imjudo®

Imlygic ™

Intravenous Immune Globulin (IVIG) Alyglo™ Asceniv™; Bivigam®; Flebogamma® DIF; Gammagard® Liquid; Gammagard® S/D; Gammaked™; Gammaplex®; Gamunex®-C; Octagam®; Panzyga®; Privigen®; Yimmugo®

Implant Removal, Breast

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

Implantable Sinus Stents and Drug-eluting Implants for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease

Implants, Palatal for the Treatment of Obstructive Sleep Apnea or Snoring

In Vitro Particle Size Measurement for Screening Hypersensitivity Reactions to Foods and Chemicals

Immune Globulins (immunoglobulin) Asceniv; Bivigam; Flebogamma; Gamunex-C; Gammagard Liquid; Gammagard S/D; Gammaked; Gammaplex; Octagam; Privigen; Panzyga (Intravenous)

IncobotulinumtoxinA

Inclisiran

Inebilizumab-cdon

Inert Gas Rebreathing Devices in the Outpatient Setting

Infant Home Apnea Monitoring / Home Cardiorespiratory Monitoring

Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™), Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), Infliximab

Ingestible pH and Pressure Capsule

Injectable Bulking Agents for the Treatment of Incontinence

Injections,

Inotersen

Inotuzumab Ozogamicin

Insulin Pumps - Diabetes Management

Integra Dermal Regeneration Template™

Intensity-Modulated Radiotherapy (IMRT) of the Breast and Lung

Intensive Outpatient Pediatric Feeding Program

Interbody Fusion

Interferential Current Stimulation

Intermittent Intravenous Insulin Therapy, Chronic

Intervertebral Disc Decompression using Radiofrequency Coblation (Nucleoplasty) or Laser Energy (Laser Discectomy)

Intestinal Transplantation

Intracranial Stent Placement

Intraocular Radiation Therapy for Age-Related Macular Degeneration

Intraoperative Radiation Therapy (IORT)

Intraoral Devices for the Treatment of Headaches

Intrapulmonary Percussive Ventilation

Intrastromal Corneal Ring Segments (ICRS) for Vision Correction

Intrauterine Myelomeningocele Repair

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Ipilimumab

Irinotecan Liposome Injection

Isatuzimab-irfc

Islet Cell Transplantation, Pancreatic

Ixabepilone (Ixempra®)

Izervay™

 

J

 

Jelmyto™

Jemperli®

 

K

 

Kadcyla®

Kalbitor®

Kanuma

Keratoplasty, Endothelial

Keytruda®

Kimmtrak®

KineGraph VMA™

Kinesio Taping

Kisunla™

Krystexxa®

Kymriah®

Kyphoplasty

Kyprolis®

L

 
   

Lamzede®

 

Lanadelumab-flyo

 

Lanreotide

 

Laparoscopic and Endoscopic Therapies for Gastroesophageal Reflux (GERD)

 

Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids

 

Laronidase

 

Laser Assisted Uvulopalatoplasty (LAUP)

 

Laser Device for Obtaining Blood Sample

 

Laser Therapy for Onychomycosis and Active Acne

 

LASIK (laser in situ keratomileusis)

 

Late Lyme Disease, Treatment

 

Lecanemab-irmb

 

Lemtrada®

 

Lenmeldy™

 

Leqembi™

 

Leqvio®

 

Leukine®

 

Leukocyte Histamine Release Test (LHRT)

 

Leukocyte Infusion, Donor (DLI) for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem Cell Transplant

 
Leuprolide Acetate Depot [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide Acetate Depot (3-month 22.5 mg)  
Leuprolide Acetate (Fensolvi®)  
Leuprolide Acetate (Eligard®)  
Leuprolide Mesylate (Camcevi™)  

Leuprolide Suspension (Lupron Depot-Ped®)

 

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)

 
Levoleucovorin (Fusilev™), Levoleucovorin (Khapzory®), Levoleucovorin  
Libtayo®  

Light Emitting Diode (LED) Therapy

 

Lipectomy and Liposuction for Lymphedema

 

Lipectomy for Lipedema

 

Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment

 

Liposuction

 

Liposuction and Lipectomy for Lipedema

 

Liposuction for Lymphedema

 

Lifileucel

 

Lisocabtagene Maraleucel

 

Loncastuximab Tesirine-lpyl

 

Loqtorzi

 

Lovotibeglogene Autotemcel

 
Low-Dose Radiotherapy for Non-Oncologic Indications  

Lumasiran

 

Lumbar Discectomy, Percutaneous

 

Lumbar Steroid Injections,

 
 
 

Lumbosacral Interbody Fusion

 

Lumizyme®

 

Lunsumio™

 

Lurbinectedin

 

Luspatercept-aamt

 

Luxturna®

 

Lyme Disease, Treatment

 

Lymphatic Physiologic Microsurgery for Breast Cancer-Related Lymphedema

 

Lymphedema Devices

 

Lyfgenia®

 

Lysis of Epidural Adhesions

 
   

M

 
   

Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)

 

Mammaplasty (Non-Cancerous), Breast Augmentation

 

Mammaplasty (Non-Cancerous), Reduction

 

Mammography

 

Manipulation Under Anesthesia (MUA) of the Musculoskeletal System

 

Manipulation Under Anesthesia, Spinal

 
Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Connective Tissue Disorders, Genetic Testing  

Margenza™

 

Margetuximab-cmkb (Margenza™)

 

Mastectomy for Gynecomastia

 

Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders

 

Mechanical Vertebral Augmentation

 

Mechanized Axial Spinal Distraction Therapy Devices

 

Mediator Release Test®

 

Meniscal Allografts and Synthetic Meniscus Implants

 

Mentoplasty (Chin Augmentation, Genioplasty)

 

Mepolizumab

 

Mepsevii

 

Methoxy Polyethylene Glycol-Epoetin Beta

 

Microprocessor-Controlled Prostheses for the Lower Limb

 

Microwave Ablation for Oncologic Tumors

 

Minimally Invasive Endoscopic Procedures for Weight Loss

 

Mircera®

 

Mirikizumab-mrkz (Omvoh)

 

Mirvetuximab Soravtansine-gynx

 

Mitochondrial Disorders, Genetic Testing

 

Mitomycin Gel

 

Mogamulizumab-kpkc

 

Molecular Markers in Fine Needle Aspirates of the Thyroid

 

Molecular Panel Testing of Cancers to Identify Targeted Therapies

 

Monjuvi

 

Monitors, Home Apnea Monitoring / Home Cardiorespiratory Monitoring

 

Monitors, Home Pulse Oximetry

 

Monovisc®

 

Mosunetuzumab-axgb

 

Motixafortide

 

MRI-Guided Focal Laser Ablation for Prostate Cancer

 

MRI-Guided Focused Ultrasound (MRgFUS)

 

MRI-guided Laser-induced Thermotherapy for Neurological Indications

 

Multi-biomarker Testing for Rheumatoid Arthritis

 

Multivisceral Transplantation

 

MVSAI

 

Myelomeningocele Repair, Intrauterine

 

Mylotarg™

 

Myobloc®

 

Myocardial Sympathetic Innervation Imaging for Individuals with Heart Failure

 
   

N

 
   

Nadofaragene firadenovec-vncg

 

Naglazyme®

 

Nanosphere Verigene Warfarin Metabolism Nucleic Acid Test

 

Nasal Function Studies

 

Nasal Implant, Absorbable for the Treatment of Nasal Valve Collapse

 

Natalizumab

 

Navigated Transcranial Magnetic Stimulation (nTMS)

 

Navigational Orthopedic Procedures

 

Naxitamab-gqgk (Danyelza®)

 

NC-Stat®

 

Necitumumab

 

Nedosiran

 

Needle Electromyography (EMG)

 

Negative Pressure Wound Therapy in the Outpatient Setting

 

Nelarabine

 

NeoVista Epi-Rad90 System™

 

Nerve Conduction Studies (Electrodiagnostic Assessment)

 

Nerve Graft with Radical Prostatectomy

 

Nervous System Testing, Autonomic

 

Neurofeedback

 

Neuromuscular Electrical Stimulation

 

NeuroPace RNS® System

 

Neurotomy, Facet Joint

 

Neurostimulation for the Treatment of Refractory Focal Epilepsy

 
Next-Generation Sequencing for the Assessment of Measurable Residual Disease  

Nexviazyme™

 
Niktimvo™

Nitric Oxide Monitoring System (NIOX)

 

Nivolumab/Relatlimab-rmbw

 

Nivolumab

 
Nivolumab and Hyaluronidase-nvhy  
Nogapendekin Alfa-Inbakicept-pmln   

Non-BRCA Genetic Panel Testing for Breast Cancer Risk Assessment

 

Non-Contact Ultrasound Treatment for Wounds

 

Non-invasive Positive Pressure Ventilators (In-Home Use)

 

Nonfamilial Genetic Testing for Breast Cancer Risk Assessment

 

Noninvasive Imaging Techniques for Evaluation and Monitoring of Chronic Liver Diseases

 

Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)

 

Novel Biomarkers for the Diagnosis and Management of Prostate Cancer

 

Nplate®

 

Nucala®

 

Nuchal Translucency

 

Nucleotome™

 

Nulibry™

 

Nusinersen

 

Nutritional Treatment of Inborn Errors of Metabolism

 
   

O

 
   

Oasis™ Wound Matrix

 
Obecabtagene Autoleucel  

Obinutuzumab

 

Ocrelizumab, Ocrelizumab and Hyaluronidase-ocsq

 

Ocrevus™

 

Ocrevus Zunovo™

 

Octreotide Suspension (Sandostatin® LAR Depot), Octreotide Acetate for Injectable Suspension

 

Olipudase Alfa

 

Omalizumab

 

Omvoh

 

OnabotulinumtoxinA

 

Onasemnogene Abeparvovec-xioi

 

Oncaspar®

 

Oncotype DX® for Breast Cancer

 

Oncotype DX® for Prostate Cancer

 
Onivyde™  
Onpattro®  

Opdivo®

 
Opdivo Qvantig™  

Opdualag™

 

Ophthalmologic Techniques for the Evaluation of Glaucoma

 

Optometric Vision Training/Orthoptics

 
Oral Negative Pressure Therapy Devices for The Treatment of Sleep Apnea  

OrCel™

 

Orencia®

 

Orthognathic Surgery

 

Orthopedic Applications of Stem Cell Therapy

 

Orthoptic Training for the Treatment of Vision or Learning Disabilities

 

Orthovisc®

 

Oscillating Force Delivered Vertebral Adjustment in the Evaluation and Treatment of the Spinal Column

 

Oscillating Devices for the Treatment of Respiratory Conditions

 

Osteochondral Allografting

 

Osteochondral Autografting (OCG)

 

Otoplasty

 

Outpatient Pediatric Feeding Program

 

Ovarian Cancer Tumor Markers

 

Oximetry - Home Pulse

 
Oxlumo®  
Ozurdex®  
   

P

 
   
Paclitaxel (Albumin-Bound) (Abraxane®; Paclitaxel Albumin-Bound)  

Padcev

 

Palatal Implants for the Treatment of Obstructive Sleep Apnea or Snoring

 

Palivizumab

 

Pancreas/Pancreas-Kidney/Pancreatic Islet Cell Transplantation

 

Panitumumab

 

PAP-NAP

 

Pasireotide

 

Patisiran

 

Pediatric Feeding Program

 

Pedmark®

 

Pegaspargase

 

Pegcetacoplan

 

Pegfilgrastim, Pegfilgrastim-jmdb, Pegfilgrastim--pbbk, Pegfilgrastim-apgf, Pegfilgrastim-fpgk, Pegfilgrastim-cbqv, Pegfilgrastim-bmez

 

Pegloticase

 

Pegunigalsidase Alfa-iwxj

 

Pelvic Floor Stimulation

 

Pembrolizumab

 
Pemetrexed (Alimta®; Pemfexy™, Pemetrexed™, Pemrydi RTU)  

Percutaneous Arteriovenous Fistula (pAVF)

 

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

 

Percutaneous Discectomy, Automated

 

Percutaneous Electrical Nerve Stimulation (PENS), Percutaneous Neuromodulation Therapy (PNT) and Percutaneous Electrical Nerve Field Stimulation (PENFS)

 

Percutaneous Sacroplasty

 

Percutaneous Techniques for the Myolysis of Uterine Fibroids

 

Percutaneous Transluminal Angioplasty, Intracranial Artery Disease (Atherosclerosis and Aneurysms)

 

Percutaneous Vertebroplasty, Kyphoplasty, and Mechanical Vertebral Augmentation

 

Peripheral Nerve Stimulation Devices as a Treatment for Pain

 

Peripheral Subcutaneous Field Stimulation for the Treatment of Pain

 

Periureteral Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR) and Incontinence

 

Perjeta®

 

Pertuzumab

 

Pertuzumab Trastuzumab and Hyaluronidase-zzxf

 

pH and Pressure Capsule

 

Pharmacogenetic Testing for Pain Management

 

Phesgo

 

Photodynamic Therapy (PDT) for the Treatment of Certain Cancers

 

Physiologic Microsurgery for Breast Cancer-Related Lymphedema

 
Piasky®  

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

 
Plasma Exchange  
Plasminogen, human-tymh  

Plugs for Anal Fistula Repair

 

Pneumatic Compression Devices for Vascular Diseases

 

Pneumatic Compression Pumps

 

Polatuzumab Vedotin-piiq

 

Polivy™

 

Pombiliti™

 

Portrazza®

 

Positron Emission Tomography (PET) for Cardiac Applications

 

Poteligeo®

 

Powered Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities

 

Pozelimab-bbfg

 

P ralatrexate

 

Pressure-specified Sensory Device Testing

 

Pro-Adjuster®

 

Proleukin®

 

Prolia®

 

Prolotherapy for Musculoskeletal Disorders

 

Prosigna

 

Prostate Specific Antigen (PSA)

 

Prosthetic Intervertebral Disc

 
Protein Profiling Assays for Breast Cancer Prognosis  

Proton Beam Therapy

 

Provenge®

 

Pulmonary Arterial Hypertension Agents

 

Pulse Oximetry, Home

 

Pulsed Light Therapy

 
   

Q

 
   

Qalsody™

 

Quantitative Sensory Testing

 
   

R

 
   

Radiation Therapy (IORT), Intraoperative

 

Radicava®

 

Radioembolization for Primary Tumors and Metastatic Tumors to the Liver

 
Radiofrequency Ablation for Nasal Obstruction and Rhinitis  

Radiofrequency Energy Transanal Treatment of Fecal Incontinence

 

Radiofrequency Tissue Volume Reduction (RFTVR) for the Treatment of Upper Airway Obstruction

 

Radiotherapy for Prostate Cancer

 

Ramucirumab

 

Ranibizumab (Lucentis®, Byooviz™; Cimerli™)

 

Ravulizumab-cwvz

 

Reblozyl®

 

Reduction Mammaplasty (Non-Cancerous)

 

Relieva®

 
Remdesivir as an Outpatient Treatment of COVID-19  

Remodulin®

 

Removal, Breast Implant

 

Removal, Hair

 

Repetitive Transcranial Magnetic Stimulation (rTMS)

 

Reslizumab

 

RespiGam®

 

Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

 

Restoration, Surgical Ventricular

 

Rethymic®

 

Retifanlimab-dlwr

 

Retinal Telescreening for Diabetic Retinopathy

 

Retisert®

 

Revcovi™

 

Rheos™ Baroreflex Hypertension Therapy™ System

 

Rhinomanometry and Acoustic Rhinometry

 

Rhinoplasty

 

RimabotulinumtoxinB

 

Risankizumab-rzaa (Skyrizi®)

 

Rituxan Hycela®

 

Rituximab and Hyaluronidase Human Injection

 
Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®],Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Non-Oncology Indications)  
Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®],Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Oncology Indications)  

Rivfloza™

 

Roctavian®

 

Rolvedon™

 

Romidepsin [Istodax®; Romidepsin (liquid)]

 

Romiplostim

 

Romosozumab-aqqg

 

Rozanolixizumab-noli

 

RTube

 
Ruconset®  
Rybrevant™  
Rylaze™  

Ryplazim®

 

Rystiggo®

 

Rytelo™

 

S

 
   

Sacituzumab Govitecan-hziy

 

Sacroiliac Joint Arthrography and Injection

 

Sacroplasty

 

Sandostatin® LAR Depot

 

Saphnelo™

 

Sarclisa

 

Sargramostim

 

Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

 

SAVER

 

SCIG (Immune Globulin SQ): Hizentra®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®

 

Sebelipase Alfa

 

Secca™ System

 

Secukinumab

 

Selective Internal Radiation Therapy (SIRT) via Microspheres for Primary and Metastatic Tumors of the Liver

 

Self-Expanding Absorptive Ostial Dilation for Treatment of Rhinosinusitis

 

Sensory and Auditory Integration Therapies

 

Serum Biomarker Human Epididymis Protein 4 (HE4)

 

Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases

 

Shingrix®

 

Signal Averaged Electrocardiography (SAECG)

 

Signifor® LAR

 

Siltuximab

 

Simponi Aria®

 

Sinus Spacers/Stents

 

Sipuleucel-T

 

Sirolimus albumin-bound

 

SIR-Spheres®

 

Skin and Soft tissue Substitutes

 

Skysona®

 

Small Bowel/Small Bowel-Liver/Multivisceral Transplantation

 

SmartPill® GI Monitoring System

 

Sodium Thiosulfate

 

Soft tissue Substitutes

 

Soliris®

 

Somatuline® Depot

 

Somnoplasty

 

Sonogram - Nonoperative Diagnostic Spinal Ultrasound (Echography)

 

Sotatercept-csrk

 

Spesolimab

 

Spevigo®

 

Spinal Cord Stimulation for Treatment of Pain

 

Spinal Manipulation Under Anesthesia

 

Spinal Ultrasound, Nonoperative Diagnostic (Echography/Sonogram)

 

Spinal Visualization, Dynamic

 

Spinraza®

 

Spirometry - Home

 

SporTX Stimulator

 

Stelara®

 

Stem Cell Therapy for Orthopedic Applications

 

Stem Cell Therapy for Peripheral Artery Disease

 

Steroid Injections,

 
 
 

Steroid-Eluting and Non-Steroid-Eluting Sinus Stents

 

Stimulation, Pelvic Floor

 

Stimufed®)

 

Stretta™

 

Subtalar Arthroereisis

 

Supartz® / Supartz® FX

 

Supprelin® LA

 

Sural Nerve Graft in Association with Radical Prostatectomy

 

Surface Electromyography (sEMG)

 

Surgeries for Athletic Groin Pain

 

Surgical Treatment of Femoroacetabular Impingement

 

Surgical Ventricular Restoration

 

Sutimlimab-jome

 

Syfovre™

 

Sylvant ®

 

Symmetry Surgery Following Mastectomy

 

Synagis®

 

Synojoynt

 

Synthetic Meniscus Implants

 

Synvisc® / Synvisc-One®

 
   

T

 
   

TACE

 

Tafasitamab-cxix

 

Tagraxofusp-erzs

 

Takhzyro®

 

Taliglucerase Alfa

 

Talimogene Laherparepvec

 

Talquetamab-tgvs

 

Talvey™

 

Tarlatamab-dlle

 

Tebentafusp-tebn

 

Tecartus

 
Tecelra®)  

Tecentriq®

 
Tecentriq Hybreza™  

Teclistamab-cqyv

 

Tecvayli™

 

Teflon® Injections

 

Tegsedi™

 

Telescreening for Diabetic Retinopathy

 

Temodar®

 

Temozolomide for Injection

 
Temsirolimus  
Tepezza®  

Teprotumumab-trbw

 

Testopel®

 

Testosterone Pellets

 
Tevimbra™  

Tezepelumab-ekko

 

Tezspire™

 

ThAIRapy® Vest (Bronchial Drainage System)

 

TheraSpheres®

 

Thermal Medial Radiofrequency Denervation

 

Thermography

 

Thermotherapy, Transpupillary (TTT)

 

Thoracic Electrical Bioimpedance and Inert Gas Rebreathing Devices in the Outpatient Setting

 

Thread Lift

 

Thyrotropin Alfa (Thyrogen®)

 

Tildrakizumab-asmn

 

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

 

Tisagenlecleucel

 
Tislelizumab-jsgr  
Tisotumab Vedotin-tftv  
Tivdak™  

Tocilizumab (Actemra®); Tocilizumab-bavi (Tofidence™)

 

Tofersen

 

Tomosynthesis, Digital Breast

 

Toripalimab-tpzi

 

Torisel®

 

Total Ankle Replacement

 

Total Artificial Heart (TAH)

 

Total Facet Arthroplasty

 

Total Parenteral/Enteral Nutrition

 
TR3ISVR™ Surgical Ventricular Restoration System  
Trabectedin  

Transcatheter Hepatic Arterial Chemoembolization

 

Transcervical Techniques for the Myolysis of Uterine Fibroids

 

Transcranial Magnetic Stimulation (TMS)

 

Transcutaneous Electrical Nerve Stimulation (TENS) and Transcutaneous Afferent Patterned Stimulation (TAPS)

 

TransCyte™

 

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

 

Transluminal Angioplasty, Percutaneous of Intracranial Atherosclerotic Stenoses With or Without Stenting

 

Transplantation, Human Organ and Tissue,

 
 
 
 
 

Transpupillary Thermotherapy (TTT)

 

Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

 

Trastuzumab Products (Herceptin®, Ontruzant®, Herzuma®, Ogivri®, Trazimera™, Kanjinti™, Hercessi™)

 

Trastuzumab and Hyaluronidase-oysk

 

Travoprost Intracameral Implant (iDose TR®)

 

Treatment for Lyme Disease

 

Treatment of Tinnitus

 

Treatments for Athletic Groin Pain

 

Trelstar®

 
Tremfya®  

Tremelimumab-actl

 

Treprostinil injection (Remodulin®); Treprostinil

 

Trigger Point Injections

 

Trilaciclib

 

Triamcinolone Acetonide Injectable Suspension (Suprachoroidal)

 
Triluron™  
Triptodur®  

Triptorelin

 

Triptorelin Pamoate

 

TriVisc™

 

Trodelvy™

 

Trogarzo™

 

Tumor Markers, Ovarian Cancer

 

Tysabri®

 
   

U

 
   

Ublituximab-xiiy

 

Ultomiris®

 

Ultrafast CT -

 
 

Ultrasonographic Measurements of Carotid Intima-Medial Thickness (CIMT) as an Assessment of Subclinical Atherosclerosis

 

Ultrasound,

 
 

Uplizna™

 

Upper Limb Myoelectric Orthosis

 

Urethral Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR) and Incontinence

 

Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral Medications for Hepatitis C

 
Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™)  
   

V

 
   

Vabysmo™

 

Vacuum Assisted Closure for Wound Healing

 

Valoctocogene Roxaparvovec-rvox

 

VAX-D®

 

Vectibix®

 

Vedolizumab

 

Veklury®

 

Velaglucerase Alfa

 

Velmanase Alfa-tycv

 

Ventricular Restoration, Surgical

 

Veopoz®

 

Vertebral Axial Decompression

 

Vertebral Fracture Assessment with Densitometry

 

Vertebral Motion Analysis

 

Vertebroplasty, Percutaneous

 

Verteporfin

 

Vesicoureteral Reflux (VUR)

 

Vestronidase Alfa-vjbk

 

Vidaza®

 

Videofluoroscopy

 

Viltepso™

 

Viltolarsen

 

Vimizim®

 

Visco-3®

 

Vision Therapy

 

Visudyne®

 

Voretigene Neparvovec-rzyl

 

Vpriv®

 

Vulvectomy

 

Vutrisiran

 
Vyepti®  

Vyjuvek™

 
Vyloy®  
Vyxeos™  
   

W

 
   

Warfarin Dose, Genetic Testing

 

Wearable Cardioverter Defibrillator

 
Wezlana™  

Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition

 
WinrevairI™  
Wound Therapy, Negative Pressure (NPWT) in the Outpatient Setting  
   

X

 
   

Xenpozyme™

 

Xeomin®

 

Xiaflex®

 

Xipere®

 

Xolair®

 
   

Y

 
   
Yervoy®  

Yescarta™

 

Yondelis®

 

Yutiq®

 
   

Z

 
   

Zaltrap®

 
Zanidatamab-hrii  
Zenocutuzumab-zbco  
Zepzelca™  
Ziihera®  

Ziv-Aflibercept

 

Zoladex®

 
Zolbetuximab-clzb  

Zoledronic Acid (Reclast®)

 
Zoledronic Acid (Zometa®)  

Zolgensma®e

 
Zoster Vaccine Recombinant, Adjuvanted  
Zynlonta™  

Zynteglo®

 

Zynyz™

 

 

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