BlueCross BlueShield of Tennessee Medical Policy Manual

Musculoskeletal

• Artificial Intervertebral Disc

• Autologous Chondrocyte Implantation (ACI)

• Automated Percutaneous and Endoscopic Discectomy

• A xial Lumbosacral Interbody Fusion

• C ervical Traction Devices for Home Use

• C omputer Assisted Surgical Navigation for Orthopedic Procedures

• Continuous Passive Motion (CPM) Device in the Home Setting

• Diagnosis and Treatment of Sacroiliac Joint Pain

• Dynamic Spinal Visualization and Vertebral Motion Analysis

• E lectrical and Electromagnetic Stimulation for the Treatment of Arthritis

• Epidural Steroid Injections for Treatment of  Back Pain

• Facet Arthroplasty

• Facet Joint Injections

• Facet Joint Neurotomy

• Genetic Testing for Facioscapulohumeral Muscular Dystrophy

• Genetic Testing for Mitochondrial Disorders

• Hand and/or Face Transplantation (Composite Tissue Allotransplantation)

• Image-Guided Minimally Invasive Decompression for Spinal Stenosis

• I ntervertebral Disc Decompression using Radiofrequency Coblation (Nucleoplasty) or Laser Energy (Laser Discectomy)

• Kinesio Taping

• L ysis of Epidural Adhesions

• Manipulation Under Anesthesia (MUA) of the Musculoskeletal System

• Mechanized Axial Spinal Distraction Therapy Devices

• Meniscal Allografts and Synthetic Meniscus Implants

• Mentoplasty (Chin Augmentation, Genioplasty)

• M icroprocessor-Controlled Prostheses for the Lower Limb

• Multi-biomarker Testing for Rheumatoid Arthritis

• Orthognathic Surgery

• O rthopedic Applications of Stem Cell Therapy

• Osteochondral Allografting

• Osteochondral Autografting (OCG)

• Percutaneous Sacroplasty

• Percutaneous Vertebroplasty, Kyphoplasty, and Mechanical Vertebral Augmentation

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

• Powered Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities

• Prolotherapy for Musculoskeletal Disorders

• S ubtalar Arthroereisis

• S urgical Treatment of Femoroacetabular Impingement

• Total Ankle Replacement

• T reatments for Athletic Groin Pain

• T rigger Point Injections

• U pper Limb Myoelectric Orthosis

• Vertebral Fracture Assessment with Densitometry

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