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 Products: Denosumab (Xgeva®); Denosumab-bmwo (Osenvelt®); Denosumab-bbdz (Wyost®); Denosumab-dssb (Xbryk™)

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    
Remestemcel-L-rknd     

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™    
Ryoncil®    

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 Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab-aekn    
     

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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