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 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
Aflibercept (Eylea®; Eylea®HD)
Agalsidase Beta

Aldesleukin

Aldurazyme®

Alemtuzumab

Alglucosidase Alfa

Aliqopa®

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 (Saphnelo™)

Ankle - Total Replacement

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

Asceniv

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

Asparlas™

Atezolizumab

Avacincaptad Pegol

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
Avalglucosidase Alfa-ngpt

Avelumab

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®

Berinert®

Beremagene Geperpavec-svdt

Besponsa®

Betibeglogene autotemcel

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

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

Bivigam®

Blinatumomab

Blincyto®

Bortezomib (Velcade®, Bortezomib)

Botulinum Toxin (Botox®)

Brachytherapy for Non-Melanoma Skin Cancer

Breast, Magnetic Resonance Imaging (MRI)

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

Celiac Disease - Serologic Diagnosis

Cell-free Fetal DNA (cffDNA)

CellSearch™

Cellular Cardiomyoplasty

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 Multi-Panel Testing and Circulating Tumor Cells (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

Copanlisib

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

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

Daunorubicin and Cytarabine Liposome for Injection

DaxibotulinumtoxinA-lanm

Daxxify™

Defibrillator, Wearable Cardioverter

Deflux®

Degarelix

Delandistrogene moxeparvovec-rokl

Denosumab (Prolia®)

Denosumab (Xgeva®)

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 Implant

Diabetes Management

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

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)

Dilated Cardiomyopathy, Genetic Testing

DISC Nucleoplasty™

Discectomy, Percutaneous

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 Wounds

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

Endovascular Therapies for Extracranial Vertebral Artery Disease

Enfortumab Vedotin-ejfv
Enhertu®

Enjaymo

Enteral Nutrition/Home Hyperalimentation

Enteryx™

Entyvio®

Epcoritamab-bysp

Epicel®

Epidural Adhesiolysis

Epidural Steroid Injections for Treatment of Back Pain

Epilepsy, Genetic Testing

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

Firazyr®

Firmagon®

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

Fistula Plugs

Flebogamma® 5% DIF/Flebogamma® 10% DIF

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 Magnetic Resonance Imaging (fMRI)

Functional Neuromuscular Electrical Stimulation

Fyarro

 

G

 

Galsulfase

Gamifant™

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

Gammagard® Liquid (Subcutaneous)

Gammaked® (Intravenous)

Gammaked® (Subcutaneous)

Gammaplex® 5% Liquid

Gamunex®-C (Intravenous)

Gamunex®-C (Subcutaneous)

Gastric Electrical Stimulation

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

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

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

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

GenVisc® 850

GERD - Transesophageal Endoscopic Therapies

Givlaari

Givosiran

Glofitamab-gxbm

Glycosylated Hemoglobin A1c Screening

Golimumab for Intravenous Infusion

Golodirsen
Goserelin Acetate

 

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)

Heartflow

Hematopoietic Progenitor Cell (HPC) Boost

Hematopoietic Stem-Cell Transplantation,

Hemodialysis in the Home

Hemoglobin A1c Screening, Glycosylated

Hemgenix®

Herceptin Hylecta

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

Hippotherapy

Histerlin

Hizentra®

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

Hypoglossal Nerve Stimulation

HyQvia®

 

I

 

Ibalizumab-uiyk

Icatibant

Idecabtageme Vicleucel (Abecma®)

IDET, Intradiscal Electrothermal Annuloplasty

Idursulfase

IG-MILD for Spinal Stenosis

Ilaris®

Ilumya™

Iluvien®

Image-Guided Minimally Invasive Decompression for Spinal Stenosis

Imfinzi®

Imiglucerase

Imjudo®

Imlygic

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

Implant Removal, Breast

Implantable Hypoglossal Nerve Stimulation

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 (Remicade®; Inflectra™; Renflexis™; Avsola™,Infliximab*)

Infusion of Growth Factors

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

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

Intermittent Intravenous Insulin Therapy, Chronic

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

Intracranial Stent Placement

Intradiscal Annuloplasty and Intraosseous Radiofrequency Ablation for Treatment of Back Pain

Intraocular Radiation Therapy for Age-Related Macular Degeneration

Intraoperative Radiation Therapy (IORT)

Intraosseous Radiofrequency Ablation for Treatment of Back Pain

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®

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

Kimmtrak®

KineGraph VMA™

Kinesio Taping

Krystexxa®

Kymriah®

Kyphoplasty

Kyprolis®

L

 

Lactase Insufficiency, Genetic Testing

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®

Leqembi™

Leqvio®

Leukine®

Leukocyte Histamine Release Test (LHRT)

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

Leuprolide Suspension (Camcevi™)

Leuprolide Suspension (Eligard®)

Leuprolide Suspension (Fensolvi®)

Leuprolide Suspension (Lupron Depot-Ped®)

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot)#1

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot)#2

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

Lumasiran

Lumbar Discectomy, Percutaneous

Lumbar Steroid Injections,

Lumbosacral Interbody Fusion

Lumizyme®

Lumoxiti®

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)

Magnetic Resonance Imaging (fMRI) - Functional

Magnetic Resonance Imaging (MRI) of the Breast

Mammaplasty (Non-Cancerous), Breast Augmentation

Mammaplasty (Non-Cancerous), Reduction

Mammography

Manipulation Under Anesthesia (MUA) of the Musculoskeletal System

Manipulation Under Anesthesia, Spinal

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

Microarray-based Gene Expression Testing for Cancers of Unknown Primary

Microprocessor-Controlled Prostheses for the Lower Limb

Microwave Ablation for Oncologic Tumors

Image-Guided Minimally Invasive Decompression for Spinal Stenosis

Minimally Invasive Endoscopic Procedures for Weight Loss

Mircera®

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

Moxetumomab pasudotox-tdfk

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

Nexviazyme

Nitric Oxide Monitoring System (NIOX)

Nivolumab/Relatlimab-rmbw

Nivolumab

Non-BRCA Genetic Panel Testing for Breast Cancer Risk Assessment

Non-Contact Ultrasound Treatment for Wounds

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 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

Obinutuzumab

Ocrelizumab (Ocrevus)

Octagam® 5% / Octagam® 10%

Octreotide Suspension

Olipudase Alfa

Omacetaxine Mepesuccinate

Omalizumab

OnabotulinumtoxinA

Onasemnogene Abeparvovec-xioi

Oncaspar®

Oncotype DX® for Breast Cancer

Oncotype DX® for Prostate Cancer

Onivyde
Onpattro®

Opdivo®

Opdualag™

Ophthalmologic Techniques for the Evaluation of Glaucoma

Optometric Vision Training/Orthoptics

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

OVA1

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

Pathwork® Tissue of Origin Test

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™)

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 Intradiscal Radiofrequency Thermocoagulation for the Treatment of Discogenic Pain

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

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

Plasma Exchange
Plasminogen, human-tymh

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

Polatuzumab Vedotin-piiq

Polivy

Pombiliti™

Portrazza®

Positron Emission Mammography

Positron Emission Tomography (PET),

Poteligeo®

Powered Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities

Pozelimab-bbfg

Pralatrexate

Pressure-specified Sensory Device Testing

Privigen®

Pro-Adjuster®

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

Proleukin®

Prolia®

Prolotherapy for Musculoskeletal Disorders

Prosigna

Prostate Specific Antigen (PSA)

Prostatic Urethral Lift

Prosthetic Intervertebral Disc

Proteomic Testing in Non-Small Cell Lung Cancer

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

Proton Beam Therapy

Provenge®

Pulmonary Arterial Hypertension Agents

Pulse Oximetry, Home

Pulsed Light Therapy

 

Q

 

Qalsody™

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

Quantitative Sensory Testing

 

R

 

Radiation Therapy (IORT), Intraoperative

Radicava®

Radioembolization for Primary Tumors and Metastatic Tumors to the Liver

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™)

Ranibizumab (Susvimo)

Ravulizumab-cwvz

Reblozyl®

Reduction Mammaplasty (Non-Cancerous)

Relieva®

Remdesivir as an Outpatient Treatment of COVID-19

Remodulin®

Removal, Breast Implant

Removal, Hair

Repetitive Transcranial Magnetic Stimulation (rTMS)

Reslizumab

RespiGam®

Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

Restoration, Surgical Ventricular

Rethymic®

Retifanlimab-dlwr

Retinal Prosthesis

Retinal Telescreening for Diabetic Retinopathy

Retisert®

Revcovi

Rheos Baroreflex Hypertension Therapy System

Rhinomanometry and Acoustic Rhinometry

Rhinoplasty

RimabotulinumtoxinB

Risankizumab-rzaa (Skyrizi®)

Rituxan Hycela®

Rituximab and Hyaluronidase Human Injection

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

Rivfloza™

Roctavian®

Rolvedon

Romidepsin [Istodax®; Romidepsin (liquid)]

Romiplostim

Romosozumab-aqqg

Rozanolixizumab-noli

RTube

Ruconset®
Rybrevant™
Rylaze™

Ryplazim®

Rystiggo®

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®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® (Subcutaneous)

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

Serologic Diagnosis of Celiac Disease

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)

Spesolimab

Spevigo®

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

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 Deactivation of Headache Trigger Sites

Surgical Treatment of Femoroacetabular Impingement

Surgical Ventricular Restoration

Susvimo

Sutimlimab-jome

Syfovre™

Sylvant ®

Symmetry Surgery Following Mastectomy

Synagis®

Synojoynt

Synribo®

Synthetic Meniscus Implants

Synvisc® / Synvisc-One®

 

T

 

TACE

Tafasitamab-cxix

Tagraxofusp-erzs

Takhzyro®

Taliglucerase Alfa

Talimogene Laherparepvec

Talquetamab-tgvs

Talvey™

Tebentafusp-tebn

Tecartus

Tecentriq®

Teclistamab-cqyv

Tecvayli™

Teflon® Injections

Tegsedi

Telescreening for Diabetic Retinopathy

Temodar®

Temozolomide for Injection

Temsirolimus
Tepezza®

Teprotumumab-trbw

Testopel®

Testosterone Pellets

Tezepelumab-ekko

Tezspire

ThAIRapy® Vest (Bronchial Drainage System)

TheraSpheres®

Thermal Medial Radiofrequency Denervation

Thermography

Thermotherapy, Transpupillary (TTT)

Thoracic Aortic Aneurysms and Dissections - 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

Tisotumab Vedotin-tftv
Tivdak

Tocilizumab

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™)

Trastuzumab and Hyaluronidase-oysk

Treatment for Lyme Disease

Treatment of Tinnitus

Treatments for Athletic Groin Pain

Trelstar®

Tremelimumab-actl

Treprostinil for Continuous Subcutaneous/Intravenous Infusion

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,

Unloading Devices, Spinal for the Treatment of Low Back Pain

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

 

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™

Vyxeos™
 

W

 

Warfarin Dose, Genetic Testing

Wearable Cardioverter Defibrillator

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

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

X

 

Xenpozyme™

Xeomin®

Xiaflex®

Xipere®

Xolair®

 

Y

 
Yervoy®

Yescarta

Yondelis®

Yutiq®

 

Z

 

Zaltrap®

Zepzelca

Ziv-Aflibercept

Zoladex®

Zoledronic Acid

Zolgensma®e

Zoster Vaccine Recombinant, Adjuvanted
Zynlonta™

Zynteglo®

Zynyz™

 

This document has been classified as public information.