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

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

Ablation Procedure for Peripheral Neuromas

Ablation Treatments for Barrett’s Esophagus

AbobotulinumtoxinA

Abraxane®

Accelerated Partial Breast Irradiation for Breast Cancer

Acclarent Balloon Sinuplasty™

aCGH for the Genetic Evaluation of Individuals with Developmental Delays/Intellectual Delays or Autism Spectrum Disorder

Acoustic Rhinometry

Actemra®

Acthar® Gel - H.P.

Actigraphy

Acupuncture

Adagen®

Adcetris®

Adhesiolysis, Epidural for Chronic Pain Syndrome

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

Ado-Trastuzumab Emtansine

Adoptive Immunotherapy

Aflibercept

Agalsidase Beta

Aldesleukin

Aldurazyme®

Alemtuzumab

Alglucosidase Alfa

Alimta®

Aliqopa®

Allergy Testing,

AlloDerm®

Allograft Transplantation, Meniscal

Allografting, Osteochondral

Allomap™

Aloxi®

Alpha1-Proteinase Inhibitor Therapy

Alternative Medicine

Amniotic Membrane and Amniotic Fluid Injections

AmpliChip CYP450 Test

Analysis of MGMT (O6-methylguanine-DNA methyltransferase) Promoter Methylation in Malignant Gliomas

Analysis of Proteomic Patterns in Serum for Early Detection of Cancer

Anesthetics for the Treatment of Chronic Pain

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

Ankle - Total Replacement

Antigens, Ovarian-Tumor Assoc. Assay

Apligraft®

Apolipoprotein B Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

Apolipoprotein E Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

Apolipoprotein I Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

Applied Behavioral Analysis (ABA)

Aqueous Shunts and Stents for Glaucoma

Aralast®-NP

Aranesp®

Arranon®

Array Analysis for the Genetic Evaluation of Individuals with Developmental Delays/Intellectual Delays or Autism Spectrum Disorder

Art-Assist Device™

Arthroereisis Implant for the Treatment of Flexible Flatfoot Conditions

Arthrography, Sacroiliac Joint

Artificial Intervertebral Disc

Artificial Liver Assist Devices for the Treatment of Liver Conditions

Artificial Pancreas Device System

Arzerra®

Atezolizumab

Auditory Integration Therapies

Auricular Electrostimulation

Autologous Cell Therapy for the Treatment of Damaged Myocardium

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

Avastin®

Avelumab

Axial Lumbosacral Interbody Fusion

Axicabtagene Ciloleucel

Azacitidine

 

B

 

Balloon and Self-Expanding Absorptive Ostial Dilation for Treatment of Chronic Sinusitis

Balloon-based Radiofrequency Ablation for Barrett’s Esophagus

Bariatric Surgery

Baroreflex Stimulation Devices

Bavencio®

Beleodaq®

Belimumab

Belinostat

Bendamustine HCl (Bendeka®)

Bendamustine HCl (Treanda®)

Benlysta®

Benralizumab

Berinert®

Besponsa™

Bevacizumab for the Treatment of Neoplastic Disease

Biochemical Markers for Alzheimer’s Disease

Bioelectrical Impedance Spectroscopy

Bioengineered Skin and Soft Tissue Substitutes

Biofeedback and Neurofeedback

Bioimpedance - Thoracic Electrical

Bioimpedance Devices for Detection of Lymphedema

Biological Therapy / Biotherapy

Biomarker Human Epididymis Protein 4 (HE4)

Biosynthetic Fistula Plugs

Bivigam®

Blepharoplasty

Blinatumomab (Blincyto®)

Body Surface Mapping

Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Other Diseases Associated with High Bone Turnover

Bortezomib

Botulinum Toxin (Botox®)

Brachytherapy for Breast Cancer

Brachytherapy for Non-Melanoma Skin Cancer

Brachytherapy for Prostate Cancer

BRCA1, BRCA2 and PALB2 Testing for Breast, Ovarian and Other Cancers

Breast, Magnetic Resonance Imaging (MRI)

Breast Augmentation / Mammaplasty (Non-Cancerous)

Breast Cancer Gene Expression Assays

Breast Cancer IndexSM

Breast Cancer Tumor Markers

Breast Implant Removal

Breast Reconstructive and Symmetry Surgery Following Mastectomy

Breast Tomosynthesis, Digital

Breathmeter

Brentuximab Vedotin

Brineura

Bronchial Drainage System (Vest)

Browplasty

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

 

C

 

C-Reactive Protein, High Sensitivity (hs-CRP) Testing for Cardiovascular Disease (CVD)

C1 Esterase Inhibitor (Berinert®)

C1 Esterase Inhibitor (Cinryze®)

C1 Esterase Inhibitor (Ruconest®)

CA - 125 Assay

Cabazitaxel

CAD of Malignancy with Magnetic Resonance Imaging of the Breast

Canakinumab

Cancer Tumor Markers,

Capecitabine

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

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

Cardioblate® Closure Device

Cardioverter Defibrillators

Carfilzomib

Carimune® NF

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

CDKN2A

Celiac Disease - Serologic Diagnosis

Cell Function Assay

Cell-free Fetal DNA (cffDNA)

CellSearch™

Cellular Cardiomyoplasty

Central Nervous System Embryonal and Ependymoma Tumors - HSCT

Cerezyme®

Cerliponase Alfa

Certolizumab Pegol

Cervarix®

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

Chemoresistance Assays - In Vitro

Chemosensitivity Assays - In Vitro

Chin Augmentation (Mentoplasty, Genioplasty)

Chondrocyte Implantation (ACI), Autologous

Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for Prenatal Evaluation and Evaluation of Children with Developmental Delays/Intellectual Disability, Autism Spectrum Disorder and/or Congenital Anomalies

Chromosomal Microarray Analysis for Evaluation of Pregnancy Loss

Cimzia®

Cineradiography

Cinqair®

Cinryze®

Circulating DNA (Liquid Biopsy) and Circulating Tumor Cells

 

Circulator Boot System

Coblation Technology

Collagen Cross Links as Markers of Bone Turnover

Collagen Cross-Linking

Collagen Implantation for Urinary Incontinence

Collagen Meniscus Implants

Collagenase Clostridium Histolyticum

Colonoscopy, Virtual (Computed Tomography Colonography)

Commercial Services Travel, Meal and Lodging Guideline

Complementary and Alternative Medicine

Composite Tissue Allotransplantation

Compounded Drug Products

Computed Tomography Angiography for Coronary Artery Evaluation

Computed Tomography Colonography (Virtual Colonoscopy)

Computed Tomography to Detect Coronary Artery Calcification

Computed Tomography (CT) Perfusion Imaging

Computed Tomography (CT) Scanning for Lung Cancer Screening

Computer Assisted Surgical Navigation for Orthopedic Procedures

Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast

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

Confocal Laser Endomicroscopy

Congenital, Treatment of Port Wine Stains and Hemangiomas

Conjunctival Challenge Test

Continuous Passive Motion (CPM) Device in the Home Setting

Cooling Devices Used in the Outpatient Setting

Copanlisib

Corneal Collagen Cross-Linking

Corneal Topography/Computer-Assisted Photokeratoscopy

Coronary Computed Tomography Angiography (CCTA)

CorRestore™ Patch System

Corticotropin Therapy

Corus CAD™

Cranial Electrotherapy Stimulation

Cryocuff®

Cryosurgical Ablation for the Treatment of Prostate Tumors

Cryosurgical Ablation for Treatment of Renal Tumors

Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal and Prostate

CT Perfusion Imaging

Current Perception Threshold Testing

Cutaneous Electrogastrography (EGG)

Cuvitru®

CyberKnife®

CYP2D6

Cyramza®

Cystic Fibrosis, Genetic Testing (CFTR-mutations)

Cytarabine Liposome for Injection

Cytochrome p450 Genotyping

Cytologic Evaluation in Breast Cancer Risk Assessment

 

D

 

Daily Hemodialysis in the Home

Daratumumab / Darzalex®

Darbepoetin Alfa

Daunorubicin and Cytarabine Liposome for Injection

Defibrillators, Cardioverter

Deflux®

Degarelix

Denosumab

Dermagraft®

Detection and Quantification of Circulating Tumor Cells in the Management of Individuals with Cancer

DEXA or DXA for Vertebral Fracture Assessment

DEXA to Determine Body Composition

Dexamethasone Intravitreal Implant

Diabetes Management

Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis

Diagnosis and Treatment of Facet Joint Pain

Diagnosis and Treatment of Sacroiliac Joint Pain

Diagnosis of Inherited Peripheral Neuropathies, Genetic Testing

Diagnostic Spinal Ultrasound (Echography/Sonogram), Nonoperative

Diapulse® Wound Treatment System™

Digital Breast Tomosynthesis

Digital Motion X-ray (DMX)

Dilated Cardiomyopathy, Genetic Testing

DISC Nucleoplasty™

Discectomy, Percutaneous

DNA-Based Testing for Adolescent Idiopathic Scoliosis (AIS)

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

Dual X-Ray Absorptiometry for Vertebral Fracture Assessment

Durolane®

Durvalumab

Dynamic Posturography in the Assessment of Balance

Dynamic Spinal Visualization

Dynamic Splinting

Dynasplint®

Dysport®

 

E

 

Ecallantide

Echography,

Eculizumab

Edaravone

Elaprase®

Electrical Fields Therapy for the Treatment of Glioblastoma

Electrical Impedance Scanning of the Breast

Electrical Nerve Stimulation,  

Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease

Electrocardiographic Body Surface Mapping

Electrocardiography, Signal Averaged (SAECG)

Electroencephalography, Quantitative as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder (ADHD)

Electrogastrography (EGG)

Electrolysis, Removal of Hair

Electromagnetic Navigation Bronchoscopy

Electromagnetic Therapy for the Treatment of Wounds

Electromyography (EMG), Needle

Electromyography (sEMG), Surface

Electron Beam Computed Tomography (EBCT) -

Electronic Brachytherapy for Non-Melanoma Skin Cancer

Elelyso®

Eligard®

Elosulfase Alfa

Elotuzumab

Emergency Care

Empliciti™

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

EndoBarrier® Gastrointestinal Liner

Endobronchial Valves

EndoCinch™

Endoluminal Radiofrequency or Laser Ablation for Treatment of Varicose Veins

Endometrial Ablation for Treatment of Menorrhagia

Endomicroscopy - Confocal Laser

EndoPredict

Endoscopic Discectomy

Endoscopic Surgery - Natural Orifice Transluminal

Endothelial Function Assessment

Endothelial Keratoplasty

Endovascular Therapies for Extracranial Vertebral Artery Disease

Enteral Nutrition/Home Hyperalimentation

Enteryx™

Entyvio®

Epicel®

Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Individuals with Non-Small Cell Lung Cancer (NSCLC)

Epidural Adhesiolysis

Epidural Steroid Injections for Treatment of Back Pain

Epilepsy, Genetic Testing

Epiretinal Radiation Therapy for Age-Related Macular Degeneration

Epoetin Alfa (Epogen®)

Epoprostenol

Erbitux®

Eribulin Mesylate

Erythropoiesis-Stimulating Agents (ESAs)

EsophyX™

Eteplirsen

Euflexxa®

EVLT (Endovenous Laser Therapy)

ExAblate 2000

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

Exome and Genome Sequencing

Exondys 51™

Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities

External Ear Reconstruction

Eyelid Thermal Pulsation

Eylea®

 

F

 

Fabrazyme®

Face Transplantation (Composite Tissue Allotransplantation)

Facelift, Facial Thread Lift

Facet Arthroplasty

Facet Steroid Injections

Facial Thread Lift

Facioscapulohumeral Muscular Dystrophy, Genetic Testing

Fasenra®

Feather Lift

Fecal Calprotectin Testing

Femoroacetabular Impingement

Fetal Surgery for Prenatally Diagnosed Malformations

Firmagon®

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

Fistula Plugs

Flebogamma® 5% DIF/Flebogamma® 10% DIF

Flolan®

Fluocinolone Acetonide Intravitreal Implant for Diabetic Macular Edema

Fluocinolone Acetonide Intravitreal Implant for the Treatment of Uveitis

Folotyn®

Fractional Laser Treatment of Vulvovaginal Atrophy

Functional Magnetic Resonance Imaging (fMRI)

Fusilev®

 

G

 

Galsulfase

Game Ready™ Accelerated Recovery System

Gamma Knife

Gammagard® S/D /  Gammagard® Liquid (Intravenous)

Gammagard® Liquid (Subcutaneous)

Gammaked® (Intravenous)

Gammaked® (Subcutaneous)

Gammaplex® 5% Liquid

Gamunex®-C (Intravenous)

Gamunex®-C (Subcutaneous)

Gardasil® / Gardasil® 9

Gastrointestinal Cancer, Serum Tumor Markers

Gazyva®

Gel-One®

Gel-Syn™

Gemtuzumab Ozogamicin

Gender Reassignment Surgery

Gene Expression Assays - Breast Cancer

Gene Expression Profile Analysis for Prostate Cancer Management

Gene Expression Testing, Microarray-based for Cancers of Unknown Primary

Gene Expression Testing for Coronary Artery Disease

Genecept™ Assay

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

Genetic Evaluation of Individuals with Developmental Delays/Intellectual Delays or Autism Spectrum Disorder

Genetic Panel Assay for Psychiatric Disorders

Genetic Testing,

Genioplasty (Mentoplasty)

Genome Sequencing

Genotyping - Cytochrome p450

Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm

Genotyping for Chronic Hepatitis C

Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

GenVisc® 850

GERD - Transesophageal Endoscopic Therapies

Germ Cell Tumors - HSCT

Glassia®

Glycosylated Hemoglobin A1c Screening

Golimumab for Intravenous Infusion

Goserelin Acetate Implant

GPS Cancer™ Test

Granisetron Extended-Release Injection

 

H

 

H.P. Acthar® Gel

Hair Removal

Hair Transplantation

Halaven®

Hand Held Oscillatory Positive Expiratory Pressure Devices

Hand and/or Face Transplantation (Composite Tissue Allotransplantation)

Heartsbreath

Heartflow

Helium Ion Beam (Charged Particle) Radiation Therapy

Hemangiomas

Hematopoietic Stem-Cell Transplantation,

Hemodialysis in the Home

Hemoglobin A1c Screening, Glycosylated

HER-2, Genetic Testing

Herceptin®

High Sensitivity C-Reactive Protein (hs-CRP) Testing for Cardiovascular Disease (CVD)

High-Density Lipoprotein (HDL) Subclass Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

Hippotherapy

Histrelin Acetate for Central Precocious Puberty (CPP)

Histrelin Acetate Implant for Prostate Cancer

Hizentra®

Home Apnea Monitoring / Home Cardiorespiratory Monitoring

Home Hyperalimentation (Total Parenteral/Enteral Nutrition)

Home Phototherapy for Neonatal Jaundice

Home Pulse Oximetry

Home Spirometry

Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease

HPV Vaccine

Human Amniotic Membrane Grafts and Amniotic Fluid Injections

Human Epidermal Receptor Type 2 (HER 2) Testing

Human Epididymis Protein 4 (HE4)

Human Papillomavirus (HPV) Vaccine

Hyalgan®

Hyaluronan Derivatives for Intra-Articular Injection

Hymovis®

Hypertension Therapy Using Low Level Electrical Stimulation

Hypoglossal Nerve Stimulation

HyQvia®

 

I

 

Ibalizumab-uiyk

IBD First Step™

IDET, Intradiscal Electrothermal Annuloplasty

Idursulfase

IG-MILD for Spinal Stenosis

Ilaris®

Ilumya™

Iluvien®

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Imfinzi®

Imiglucerase

Imlygic ®

Immune Cell Function Assay

Implant Removal, Breast

Implantable Cardioverter Defibrillators, Transvenous or Subcutaneous

Implantable Hypoglossal Nerve Stimulation

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 Chemosensitivity and Chemoresistance Assays

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

IncobotulinumtoxinA

Inert Gas Rebreathing Devices in the Outpatient Setting

Infant Home Apnea Monitoring / Home Cardiorespiratory Monitoring

Inflectra®

Infliximab

Infliximab-abda

Infliximab-dyyb

Infusion of Growth Factors

Ingestible pH and Pressure Capsule

Injectable Bulking Agents for the Treatment of Incontinence

Injections,

Inotuzumab Ozogamicin

Insulin Pumps - Diabetes Management

Integra Dermal Regeneration Template™

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

Interbody Fusion

Interferential Current Stimulation

Interlaminar Stabilization/Distraction Devices (Spacers); Interspinous Fixation (Fusion) Devices

Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers); Interspinous Fixation (Fusion) Devices

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

Intestinal Transplantation

Intracellular Micronutrient Analysis

Intracranial Stent Placement

Intradiscal Annuloplasty for the Treatment of Discogenic Back Pain

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

Intravenous Immune Globulin (IVIG) Therapy

Ipilimumab

Irinotecan Liposome Injection

Islet Cell Transplantation, Pancreatic

Istodax®

IVIG

Ixabepilone (Ixempra®)

 

J

 

JAS™ Device

Jaundice, Home Phototherapy for Neonatal

Jetrea®

Jevtana®

 

K

 

Kadcyla®

Kalbitor®

Kanuma

Keratoplasty, Endothelial

Keratoprosthesis

Keytruda®

KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

Kinesio Taping

Krystexxa®

KYMRIAH™

Kyphoplasty

Kyprolis®

L

 

Laboratory Tests for Heart Transplant Rejection

Lactase Insufficiency, Genetic Testing

Language / Speech Therapy, Occupational Therapy and Physical Therapy for Autism Spectrum Disorder

Lanreotide

Laparoscopic and Endoscopic Therapies for Gastroesophageal Reflux (GERD)

Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids

Laronidase

Lartruvo®

Laser Assisted Uvulopalatoplasty (LAUP)

Laser Device for Obtaining Blood Sample

Laser Surgery / Treatment,

Laser Therapy for Onychomycosis and Active Acne

LASIK (laser in situ keratomileusis)

Late Lyme Disease, Testing and Treatment

Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Lemtrada®

Leukine®

Leukocyte Histamine Release Test (LHRT)

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

Leuprolide Acetate for Depot Suspension

Levoleucovorin

Liberation Procedure

Light Emitting Diode (LED) Therapy

Linear-accelerator

Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease

Lipoprotein(a) Enzyme Immunoassay in the Management of Cardiovascular Disease

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

Lipoprotein-Associated Phospholipase in the Assessment of Cardiovascular Risk

Liposuction

Liver Assist Devices for the Treatment of Liver Conditions

Low-Density Lipoprotein (LDL) Subclass Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

Lp-PLA2 Measurement in the Assessment of Cardiovascular Risk

Lucentis®

Lumbar Discectomy, Percutaneous

Lumbar Steroid Injections,

Lumbosacral Interbody Fusion

Lumizyme®

Lupron Depot® / Lupron Depot-Ped®

Luxturna™

Lyme Disease, Testing and Treatment

Lymphedema Devices

Lymphocytic Mitogen Response Assay for the Diagnosis of Vitamin, Mineral, and Antioxidant Functional Deficiencies

Lysis of Epidural Adhesions

 

M

 

Macugen®

Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)

Magnetic Resonance Imaging (fMRI) - Functional

Magnetic Resonance Imaging (MRI) - Positional

Magnetic Resonance Imaging (MRI) of the Breast

Mammaplasty (Non-Cancerous), Breast Augmentation

Mammaplasty (Non-Cancerous), Reduction

Mammography Screening

Manipulation Under Anesthesia (MUA) of the Musculoskeletal System

Manipulation Under Anesthesia, Spinal

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

Marqibo®

Mastectomy for Gynecomastia

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

Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk

Measurement of Serum Antibodies to Infliximab and Adalimumab

Mechanical Stretch Devices for the Treatment of Joint Stiffness

Mechanized Axial Spinal Distraction Therapy Devices

Mediator Release Test®

Medication Assisted Treatment for Chemical Dependency

Melaris®

Meniett Device

Meniscal Allografts and Synthetic Meniscus Implants

Mentoplasty (Chin Augmentation, Genioplasty)

Mepolizumab

Mepsevii

Methoxy Polyethylene Glycol-Epoetin Beta

MGMT (O6-methylguanine-DNA methyltransferase) Promoter Methylation in Malignant Gliomas

Microarray-based Gene Expression Testing for Cancers of Unknown Primary

Microprocessor-Controlled Prostheses for the Lower Limb

Microwave Ablation for Oncologic Tumors

Minimally Invasive Procedures for Weight Loss

Minimally Invasive Lumbar Decompression for Spinal Stenosis

Mircera®

Mitochondrial Disorders, Genetic Testing

Molecular Anatomic Pathology Testing (PathFinderTG®)

Molecular Markers in Fine Needle Aspirates of the Thyroid

Molecular Panel Testing of Cancers to Identify Targeted Therapies

Monitors, Home Apnea Monitoring / Home Cardiorespiratory Monitoring

Monitors, Home Pulse Oximetry

Monovisc®

MRI-Guided Focused Ultrasound (MRgFUS)

MRI-guided Laser-induced Thermotherapy for Neurological Indications

Multi-biomarker Testing for Rheumatoid Arthritis

Multi-gene Expression Assay for Predicting Recurrence in Colon Cancer

Multitarget Polymerase Chain Reaction (PCR) Testing for the Diagnosis of Bacterial Vaginosis

Multivisceral Transplantation

Myelomeningocele Repair, Intrauterine

Mylotarg™

Myobloc®

Myocardial Sympathetic Innervation Imaging for Individuals with Heart Failure

Myoelectric Prosthetic Components for the Upper Limb

 

N

 

Naglazyme®

Nanosphere Verigene Warfarin Metabolism Nucleic Acid Test

Nasal Function Studies

Natalizumab

Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Navigated Transcranial Magnetic Stimulation (nTMS)

Navigational Orthopedic Procedures

NC-Stat®

Necitumumab

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

Nerve Stimulation, Occipital

Nervous System Testing, Autonomic

Neulasta®

Neurofeedback

Neuromuscular Electrical Stimulation

NeuroPace RNS® System

Neurostimulation for the Treatment of Refractory Partial Epilepsy

Next-Generation Sequencing Panels for Prenatal Evaluation and Evaluation of Children with Developmental Delays/Intellectual Delays or Autism Spectrum Disorder

Nitric Oxide Monitoring System (NIOX)

Nivolumab

Non-BRCA Genetic Panel Testing for Breast Cancer Risk Assessment

Non-Contact Ultrasound Treatment for Wounds

Non-Cosmetic Pediatric Orthodontia

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

Non-Invasive Prenatal Testing Using Cell-free Fetal DNA (cffDNA)

Nonfamilial Genetic Testing for Breast Cancer Risk Assessment

Noninvasive Fractional Flow Reserve Measurement

Noninvasive Techniques for Evaluation and Monitoring of Chronic Liver Diseases

Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)

NOTES

Novel Biomarkers for the Diagnosis and Management of Prostate Cancer

Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease

Nplate®

Nucala®

Nuchal Translucency

Nucleotome™

Nusinersen

Nutritional Treatment of Inborn Errors of Metabolism

 

O

 

Oasis™ Wound Matrix

Obesity, Surgery for (Bariatric Surgery)

Obinutuzumab

Occipital Nerve Stimulation

Occupational Therapy for Autism Spectrum Disorder

Ocrelizumab (Ocrevus)

Ocriplasmin

Octagam® 5%

Octreotide Acetate Long-Acting Dosage Form

Ofatumumab

Olaratumab

Omacetaxine Mepesuccinate

Omalizumab

OnabotulinumtoxinA

Oncotype DX® for Breast Cancer

Oncotype DX® for Colon Cancer

Oncotype DX® for Prostate Cancer

Onivyde™

Opdivo®

Ophthalmologic Techniques for the Evaluation of Glaucoma

Optometric Vision Training/Orthoptics

OrCel™

Orencia®

Orifice Transluminal Endoscopic Surgery - Natural

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

Oscillatory Devices for the Treatment of Cystic Fibrosis

Osteochondral Allografting

Osteochondral Autografting (OCG)

Otoplasty

OVA1™

OvaCheck™

Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

Ovarian Cancer Tumor Markers

OvaSure™

Oximetry - Home Pulse

Ozurdex®
 

P

 

Paclitaxel (Protein-Bound)

Palatal Implants for the Treatment of Obstructive Sleep Apnea or Snoring

PALB2 Testing for Breast, Ovarian and Other Cancers

Palivizumab

Palonosetron Hydrochloride

Pancreas/Pancreas-Kidney/Pancreatic Islet Cell Transplantation

Panitumumab

PAP-NAP

Pasireotide Pamoate

PathFinderTG®

Pathwork® Tissue of Origin Test

Patient-Specific Cutting Guides and Custom Knee Implants

Pegademase Bovine

Pegaptanib Sodium

Pegfilgrastim

Pegloticase

Pelvic Floor Stimulation

Pembrolizumab

Pemetrexed

Percussion / Oscillating Devices for the Treatment of Respiratory Conditions

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

Percutaneous Discectomy, Automated

Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)

Percutaneous Intradiscal Radiofrequency Thermocoagulation for the Treatment of Discogenic Pain

Percutaneous LAA Closure Devices

Percutaneous Techniques for the Myolysis of Uterine Fibroids

Percutaneous Tibial Nerve Stimulation (PTNS)

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

Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

Peripheral Subcutaneous Field Stimulation for the Treatment of Pain

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

Peroral Endoscopic Myotomy (POEM)

Pertuzumab / Perjeta®

pH and Pressure Capsule

Pharmacogenetic Testing for Pain Management

PhiCal™

Photodynamic Therapy (PDT) for the Treatment of Certain Cancers

Photokeratoscopy, Computer-Assisted

Phototherapy, Home for Neonatal Jaundice

Physical Therapy for Autism Spectrum Disorder

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

Plasma Exchange

Platelet Rich Plasma as a Treatment for Wound Healing or Other Conditions

Plugs for Anal Fistula Repair

Pneumatic Compression Devices for Vascular Diseases

Pneumatic Compression Pumps for the Treatment of Lymphedema, DVT Prophylaxis and Venous Ulcers in the Home Setting

Polar Care Cub

Port Wine Stains, Treatment of Congenital

Portrazza®

Positional Magnetic Resonance Imaging (MRI)

Positron Emission Mammography

Positron Emission Tomography (PET),

Posterior Tibial Nerve Stimulation (PTNS) for Voiding Dysfunction

Powered Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities

Pralatrexate

Pressure-specified Sensory Device Testing

Preventive Services: Extension of Moderate and Intensive Multicomponent Intervention Visits for Obesity

Privigen®

Pro-Adjuster®

Procrit®

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

Prolastin®-C

Proleukin®

Prolia®

Prolotherapy for Musculoskeletal Disorders

Prosigna

Prostascint®

Prostate Specific Antigen (PSA)

Prostatic Urethral Lift

Prosthetic Intervertebral Disc

Proteogenomic Testing for Individuals with Cancer

Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer

Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses

Proton Beam Radiosurgery

Proton or Helium Ion Beam (Charged Particle) Radiation Therapy

PROVANT® Wound Closure System

Provenge®

PTNS for Voiding Dysfunction

Pulmonary Arterial Hypertension Agents

Pulse Oximetry, Home

Pulsed Light Therapy

 

Q

 

Quantification and Detection of Circulating Tumor Cells in the Management of Individuals with Cancer

Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder (ADHD)

Quantitative Sensory Testing

 

R

 

Radiation Therapy (IORT), Intraoperative

Radicava®

Radioembolization for Primary Tumors of the Liver and Metastatic Tumors to the Liver

Radiofrequency, Endoluminal Ablation for Treatment of Varicose Veins

Radiofrequency Ablation for Barrett’s Esophagus

Radiofrequency Ablation of Tumors

Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension

Radiofrequency Energy Transanal Treatment of Fecal Incontinence

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

Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) with Indium-111 Capromab Pendetide for Prostate Cancer

Radionics®

Radiosurgery - Stereotactic

Radiotherapeutics®

Radiotherapy for Prostate Cancer

Ramucirumab

Ranibizumab

Reclast®

Reduction Mammaplasty (Non-Cancerous)

Rejection, Laboratory Tests for Heart Transplant

Relieva®

Remicade®

Remodulin®

Removal, Breast Implant

Removal, Hair

Renflexis™

Repetitive Transcranial Magnetic Stimulation (rTMS)

Reslizumab

RespiGam®

Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy

Restoration, Surgical Ventricular

Retinal Prosthesis

Retinal Telescreening for Diabetic Retinopathy

Retisert®

Rheos™ Baroreflex Hypertension Therapy™ System

Rhinomanometry and Acoustic Rhinometry

Rhinoplasty

RimabotulinumtoxinB

RITA® - Radiofrequency Interstitial Tissue Ablation

Rituxan Hycela™

Rituximab

Rituximab and Hyaluronidase Human Injection

Romidepsin

Romiplostim

RTube

Ruconest®
 

S

 

Sacroiliac Joint Arthrography and Injection

Sacroplasty

Saliva Testing for Hormone Levels

Salivary Testing for Steroid Hormone Levels

Sandostatin® LAR Depot

Sargramostim

Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

SAVER

Sclerotherapy

ScoliScore™ AIS

Sebelipase Alfa

Secca™ System

Seed Implantation, Radioactive

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

Self-Expanding Absorptive Ostial Dilation for Treatment of Chronic Sinusitis

Sensory and Auditory Integration Therapies

Serologic Diagnosis of Celiac Disease

Serum Antibodies for the Diagnosis and Management of Inflammatory Bowel Disease: ANCA for Ulcerative Colitis and ASCA for Crohn's Disease

Serum Biomarker Human Epididymis Protein 4 (HE4)

Serum Biomarker Panel Testing for Systemic Lupus Erythematosus

Serum Holotranscobalamin as a Marker of Vitamin B12 (Cobalamin) Status

Serum Tumor Markers for Breast Malignancies

Serum Tumor Markers for Gastrointestinal Cancer

Shingrix®

Signal Averaged Electrocardiography (SAECG)

Signifor® LAR

Siltuximab

Simponi Aria®

Sinus Spacers/Stents

Sipuleucel-T

SIR-Spheres®

Skin and Soft tissue Substitutes

Small Bowel/Small Bowel-Liver/Multivisceral Transplantation

SmartPill® GI Monitoring System

Soft tissue Substitutes

Soliris®

Somatuline® Depot

Somnoplasty

Sonogram - Nonoperative Diagnostic Spinal Ultrasound (Echography)

Speech / Language Therapy, Occupational Therapy and Physical Therapy for Autism Spectrum Disorder

Spinal Cord Stimulation for Treatment of Pain

Spinal Manipulation Under Anesthesia

Spinal Ultrasound, Nonoperative Diagnostic (Echography/Sonogram)

Spinal Unloading Devices for the Treatment of Low Back Pain

Spinal Visualization, Dynamic

Spinraza™

Spirometry - Home

SporTX Stimulator

Statin-Induced Myopathy, Genetic Testing

Stelara®

Stem Cell Therapy for Orthopedic Applications

Stem Cell Therapy for Peripheral Artery Disease

Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions

Steroid Injections,

Stimulation, Pelvic Floor

Stretta™

Subcutaneous Immune Globulins

Subcutaneous Implantable Cardioverter Defibrillator

Sublingual Liquid Immunotherapy

Subtalar Arthroereisis

Supartz® / Supartz® FX

Supprelin® LA

Sural Nerve Graft in Association with Radical Prostatectomy

Surface Electromyography (sEMG)

Surgery for Morbid Obesity (Bariatric Surgery)

Surgical Deactivation of Headache Trigger Sites

Surgical Treatment of Femoroacetabular Impingement

Surgical Ventricular Restoration

Sustol®

Sylvant ®

Symmetry Surgery Following Mastectomy

Sympathetic Therapy for the Treatment of Pain

Synagis®

Synribo®

Synthetic Meniscus Implants

Synvisc® / Synvisc-One®

 

T

 

TACE

Taliglucerase Alfa

Talimogene Laherparepvec

Tecentriq ®

Teflon® Injections

Telangiectasia

Telemedicine / Telehealth

Telescreening for Diabetic Retinopathy

Temodar®

Temozolomide for Injection

Temporomandibular Joint (TMJ) Dysfunction: Diagnostic Studies

Temsirolimus

Testing and Treatment for Lyme Disease

Testopel®

Testosterone Pellets for Subcutaneous Implantation

ThAIRapy® Vest (Bronchial Drainage System)

TheraSpheres®

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

Tocilizumab (Intravenous)

Tomosynthesis, Digital Breast

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

Transcranial Magnetic Stimulation (TMS)

Transcutaneous Electrical Nerve Stimulation (TENS)

TransCyte™

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

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

Transluminal Endoscopic Surgery - Natural Orifice

Transoral NOTES

Transplantation, Human Organ and Tissue,

Transpupillary Thermotherapy (TTT)

Transtympanic Micropressure Applications as a Treatment of Ménière's Disease

Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

Transvenous Implantable Cardioverter Defibrillator

Trastuzumab

Treanda®

Treatment for Lyme Disease

Treatment of Congenital Port Wine Stains and Hemangiomas

Treatment of Germ Cell Tumors - HSCT

Treatment of Tinnitus

Trelstar®

Treprostinil for Continuous Subcutaneous/Intravenous Infusion

Trigger Point Injections

Triptorelin Extended-Release Injectable Suspension (Triptodur™)

Triptorelin Pamoate

TriVisc™

Trogarzo™

Tumor Markers,

Tumor-Treatment Fields Therapy for Glioblastoma

TVA Ground Ambulance Transport Policy

Tysabri®

 

U

 

Ultrafast CT -

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

Ultrasound,

Unloading Devices, Spinal for the Treatment of Low Back Pain

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

Urinary Tumor Markers for Bladder Cancer

Use of Opioids in Control of Acute Pain

Use of Opioids in Control of Chronic Pain

Ustekinumab

 

V

 

Vacuum Assisted Closure for Wound Healing

Vagal Nerve Blocking Therapy for Treatment of Obesity

Vantas®

Varicose Vein Treatments for the Lower Extremities

VAX-D®

Vectibix®

Vedolizumab

Velaglucerase Alfa

Velcade®

Veletri®

Ventricular Restoration, Surgical

Vertebral Axial Decompression

Vertebral Fracture Assessment with Densitometry

Vertebroplasty, Percutaneous

Verteporfin

Vesicoureteral Reflux (VUR)

Vestronidase alfa-vjbk

Vidaza®

Videofluoroscopy

Vimizim®

Vincristine Sulfate Liposome Injection

Virtual Colonoscopy (Computed Tomography Colonography)

Visco-3®

Vision Therapy

Visudyne®

VNUS® Closure™ System

Voretigene Neparvovec-rzyl

Vpriv®

Vulvectomy

VYXEOS™
 

W

 

Warfarin Dose, Genetic Testing

WATCHMAN™ Left-Atrial Appendage Closure Devices

Wearable Cardioverter Defibrillator

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

Whole Exome and Genome Sequencing

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

X

 

Xeloda®

Xeomin®

Xgeva®

Xiaflex®

Xolair®

 

Y

 

Yervoy®

Yescarta™

Yondelis®

 

Z

 

Zaltrap®

Zemaira®

Ziv-Aflibercept

Zoladex®

Zoledronic Acid

Zometa®

Zostavax®

Zoster Vaccine, Live

Zoster Vaccine Recombinant, Adjuvanted
 

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