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)

Abecma®

Ablation for Nasal Obstruction and Rhinitis, RF

Ablation Procedure for Peripheral Neuromas

AbobotulinumtoxinA

Abraxane®

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®

Allogeneic Processed Thymus Tissue-agdc

Allograft Transplantation, Meniscal

Allografting, Osteochondral

Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin®-C, Zemaira®)

Alternative Medicine

Amivantamab-vmjw

Amniotic Membrane and Amniotic Fluid Injections

Amondys 45™

AmpliChip CYP450 Test

Amtagvi

Amvuttra™

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

Carvyktil

Casgevy™

Casimersen

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

 

Circulating Tumor DNA (Liquid Biopsy)

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®

Cosibelimab-ipdl

Cranial Electrotherapy Stimulation

Crizanlizumab-tmca

Crovalimab-akkz

Cryosurgical Ablation of Solid Tumors

Crysvita®

Current Perception Threshold Testing

Cutaneous Electrogastrography (EGG)

Cuvitru®

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 Products: Denosumab (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-kyqq (Bosaya™); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-bmwo (Stoboclo®); Denosumab-bnht (Conexxence®)

Denosumab Products: Denosumab (Xgeva®); Denosumab-kyqq (Aukelso™); Denosumab-nxxp (Bilprevda®); Denosumab-bnht (Bomyntra®); 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

Efbemalenograstim alfa-vuxw 

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

Efgartigimod Alfa-fcab and Hyaluronidase-qvfc

Eflapegrastim-xnst

Eladocagene exuparvovec-tneq 

Elahere™

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™

Emrelis™

Encelto™

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 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

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

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

FoundationOne Liquid CDx®

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

Guardant360® CDx

Guselkumab 

 

H

 

H.P. Acthar® Gel

Haegarda®

Hair Removal

Hair Transplantation

Halaven®

Hand and/or Face Transplantation (Composite Tissue Allotransplantation)

Hand Held Oscillatory Positive Expiratory Pressure Devices

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

Histrelin Acetate (Supprelin® LA)

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™

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®

Imaavy™

Image-Guided Minimally Invasive Decompression for Spinal Stenosis

Imdelltra™

Imetelstat

Imfinzi®

Imiglucerase

Imjudo®

Imlygic ™

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

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

Kebilidi®

Keytruda®

Keytruda Qlex™

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 Suspension (Lupron Depot-Ped®)        

Leuprolide Acetate Depot Suspension - [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); Lutrate Depot (3-month 22.5 mg)

       

Leuprolide Acetate (Fensolvi®)

       

Leuprolide Acetate (Eligard®)

       

Leuprolide Mesylate (Camcevi ETM™; Camcevi Kit)

       

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

       

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

       

Libtayo®

       

Lifileucel

       

Light Emitting Diode (LED) Therapy

       
Linvoseltamab-gcpt         

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

       

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

       

Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto®)

       

Luxturna®

       

Lyfgenia®

       

Lyme Disease, Treatment

       

Lymphatic Physiologic Microsurgery for Breast Cancer-Related Lymphedema

       

Lymphedema Devices

       
Lynozyfic™        

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 Decompression for Spinal Stenosis

       

Minimally Invasive Endoscopic Procedures for Weight Loss

       

Mircera®

       

Mirikizumab-mrkz (Omvoh)

       

Mirvetuximab Soravtansine-gynx

       

Mitochondrial Disorders, Genetic Testing

       

Mitomycin Gel

       
Mitomycin         

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

       

Neurostimulation for the Treatment of Refractory Focal Epilepsy

       

Neurotomy, Facet Joint

       

Next-Generation Sequencing for the Assessment of Measurable Residual Disease

       

Nexviazyme™

       

Niktimvo™

       
Nipocalimab-aahu        

Nitric Oxide Monitoring System (NIOX)

       

Nivolumab

       

Nivolumab and Hyaluronidase-nvhy

       

Nogapendekin Alfa-Inbakicept-pmln 

       

Nivolumab/Relatlimab-rmbw

       

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

       

Nyvepria™

       
         

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-rpcp Alfa

       

Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)

       

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

       
Papzimeos™        

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

       
Pembrolizumab and Berahyaluronidase alfa-pmph        

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

       

Penile Prosthesis (insertion/removal)

       
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

       

Pluvicto®

       

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

       

Prademagene Zamikeracel

       

Pralatrexate

       

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

       

Radiotherapy for Prostate Cancer

       

Ramucirumab

       

Ranibizumab (Lucentis®, Byooviz™; Cimerli™)

       
Ranibizumab (Susvimo®)        

Ravulizumab-cwvz

       

Reblozyl®

       

Reduction Mammaplasty (Non-Cancerous)

       

Relieva®

       

Remestemcel-L-rknd 

       

Remodulin®

       

Removal, Breast Implant

       

Removal, Hair

       

Reslizumab

       

RespiGam®

       

Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

       

Restoration, Surgical Ventricular

       

Rethymic®

       

Retifanlimab-dlwr

       

Retinal Telescreening for Diabetic Retinopathy

       

Retisert®

       

Revakinagene Taroretcel-lwey

       

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

       

Ruconest®

       

Rybrevant™

       

Rylaze™

       

Ryoncil®

       

Ryplazim®

       

Rystiggo®

       

Rytelo™

       
Ryzneuta
         

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

       

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

       

Skyrizi®

       

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

       

Telisotuzumab vedotin-tllv

       

Temodar®

       

Temozolomide for Injection

       

Temsirolimus

       

Tepezza®

       

Teplizumab-mzwv

       

Teprotumumab-trbw

       

Testopel®

       

Testosterone Pellets

       

Tevimbra™

       

Tezepelumab-ekko

       

Tezspire™

       

ThAIRapy® Vest (Bronchial Drainage System)

       

TheraSpheres®

       

Thermal Medial Radiofrequency Denervation

       

Thermography

       

Thermotherapy, Transpupillary (TTT)

       

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

       

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 and Hyaluronidase-oysk

       

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

       

Travoprost Intracameral Implant (iDose TR®)

       

Treatment for Lyme Disease

       

Treatment for Sexual Dysfunction in Males: Non-Pharmacologic

       

Treatment of Tinnitus

       

Treatments for Athletic Groin Pain

       

Trelstar®

       

Tremfya®

       

Tremelimumab-actl

       

Treprostinil injection (Remodulin®); Treprostinil

       

Triamcinolone Acetonide Injectable Suspension (Suprachoroidal)

       

Trigger Point Injections

       

Trilaciclib 

       

Triluron™

       

Triptodur®

       

Triptorelin

       

Triptorelin Pamoate

       

TriVisc™

       

Trodelvy™

       

Trogarzo™

       

Tumor Markers, Ovarian Cancer

       

Tyruko®

       

Tysabri®

       

Tzield™

       
         

U

       
         

Ublituximab-xiiy

       

Ultomiris®

       

Ultrafast CT -

       
       

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

       

Ultrasound,

       
       
Unloxcyt™        

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; ustenkinumab-ttwe

       
         

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®

       

Vyondys-53™

       

Vyvgart®Hytrulo

       

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®

       
         

Y

       
         

Yervoy®

       

Yescarta™

       

Yondelis®

       

Yutiq®

       
         

Z

       
         

Zaltrap®

       

Zanidatamab-hrii

       

Zenocutuzumab-zbco

       

Zepzelca™

       

Zevaskyn™

       

Ziextenzo™

       

Ziihera®

       

Ziv-Aflibercept

       

Zoladex®

       

Zolbetuximab-clzb

       

Zoledronic Acid (Reclast®)

       

Zoledronic Acid (Zometa®)

       

Zolgensma®e

       

Zoster Vaccine Recombinant, Adjuvanted

       
Zopapogene Imadenovec-drba         
Zusduri™        
Zynlonta™        

Zynteglo®

       

Zynyz™

       

 

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