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Alternative Medicine

• Acupuncture, Auricular Electrostimulation (e.g., E-Pulse, P-Stim™) Policy 8.01.20 (posted 5/31/18)
• Biofeedback, EMG Biofeedback Policy 2.01.09 (posted 11/19/18)

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Anesthesiology

• Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Surgery Policy 7.03.01 (posted 1/18/19)
• Monitored Anesthesia Care (MAC) Policy 7.03.02 (posted 6/12/18)

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Behavioral Health (Psychology)

• Applied Behavioral Analysis for Treatment of Autism Spectrum Disorders (ABA), Pervasive Developmental Disorders (PDD) Policy 3.01.11 (posted 1/18/19)
• Behavioral Health Treatment for Gender Dysphoria: Gender Identity Disorder (GID), Intersex, Transexualism Policy 3.01.15 (posted 11/26/18)
• Behavioral Health Treatment of Family and Couples (Couples Therapy, Family Therapy) Policy 3.01.05 (posted 4/4/18)
• Group Therapy for Mental Health Policy 3.01.08 (posted 1/18/19)
• Hypnosis Policy 2.01.26 (posted 10/09/18)
• Ketamine for the Treatment of Psychiatric Disorders Policy 3.01.13 (posted 2/06/19)
• Medication Assisted Therapy (e.g., Buprenorphine, LAAM, Methadone Maintenance Treatment, Ultra-rapid Detoxification), Opioid Treatment Policy 3.01.04 (posted 1/18/19)
• Partial Hospitalization for Substance Use Disorders, Chemical Dependency Policy 3.01.18 (posted 11/26/18)
• Phototherapy/Light Therapy for Seasonal Affective Disorder (SAD) Policy 1.01.24 (posted 11/26/18)
• Psychological Testing Policy 3.01.02 (posted 1/18/19)
• Sex Offender Treatment Program Policy 3.01.17 (posted 11/26/18)
• Sex Specific Services, Gender dysphoria, Gender Identity Disorder, GID, transgender, transsexualism Policy 11.01.26 (posted 1/18/19)
• Standard Dialectical Behavioral Therapy (DBT) Policy 3.01.10 (posted 11/26/18)
• Transcranial Magnetic Stimulation: Deep TMS device, MagVita TMS, NeuroStar TMS device, rTMS, TMS Policy 3.01.09 (posted 1/18/19)
• Treatment of Gambling Disorder and Other Repetitive Behaviors Policy 3.01.19 (posted 4/11/18)

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Blood Disorders (Hematology)

• Chelation Therapy (e.g., EDTA, Endrate, Desferal, BAL in oil, Cuprimine, Depen, Zinecard, Exjade, Post-chelator Challenge Urinary Metal Testing. Post-provocation Urinary Metal Testing) Policy 8.01.03 (posted 11/19/18)
• Plasmapheresis, Plasma Exchange and Apheresis, Rheopheresis Policy 8.01.04 (posted 3/26/19)

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Bone & Joints (Orthopedic)

• Artificial Cervical Intervertebral Discs (e.g., Bryan, Mobi-C, PCM [Porous Coated Motion] Cervical Disc®, Prestige®, ProDisc®, Secure-C) Policy 7.01.80 (posted 3/26/19)
• Artificial Lumbar Intervertebral Disc (e.g.,ActivL®, Bryan, Charité, ProDisc) Policy 7.01.63 (posted 1/15/19)
• Autologous Chrondrocyte Implantation (e.g., Carticel®, Matrix-induced ACI, MACI, Minced cartilage, Neocartilage, Scaffold-induced ACI) Policy 7.01.38 (posted 8/16/18)
• Automated Percutaneous and Endoscopic Discectomy: Stryker DeKompressor, Nucleotome, SpineJet Hydrodiscectomy Policy 7.01.16 (posted 8/16/18)
• Bone Growth Stimulators (e.g., Electrical, Osteogenic, Sonic Accelerated Fracture Healing System - SAFHS, Ultrasonic) Policy 7.01.40 (posted 4/4/18)
• Computerized Motion Diagnostic Imaging (CMDI), Gait Analysis Policy 2.01.13 (posted 2/06/19)
• Cryotherapy, Cold Therapy, Ice Therapy Policy 1.01.21 (posted 8/16/18)
• Dynamic Adjustable Braces/Joint Extension Device (e.g., Dynasplint™, EMPI Advance™, LMB Proglide™, Ultraflex™ Policy 1.01.35 (posted 4/4/18)
• Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds: Lithotripsy, Orthotripsy, OssaTron®, EpoUltra®, SINOCUR®, Orbasone™, Orthospec™ Policy 2.01.31 (posted 8/16/18)
• Hip Arthroplasty Policy 7.01.96 (posted 1/15/19)
• Interspinous and Interlaminar Stabilization/Distraction Implants (e.g., Coflex®, Interspinous Spacer, Spinal Distraction, Superion®, X STOP) Policy 7.01.75 (posted 8/16/18)
• Intervertebral Disc Decompression: Laser (Laser Discectomy) and Radiofrequency Coblation (Disc Nucleoplasty™) Techniques Policy 7.01.62 (posted 8/16/18)
• Lumbar Decompression Policy 7.01.97 (posted 1/15/19)
• Lumbar Fusion for Adults Policy 7.01.90 (posted 2/06/19)
• Lumbar Microdiscectomy Policy 7.01.98 (posted 1/15/19)
• Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices - ComfortTrac, Decompression Reduction Stabilization (DRS) System, HomeTrac, Orthotrac, VAX-D Policy 1.01.50 (posted 9/6/18)
• Lysis of Epidural Adhesions, Adhesiolysis, Epidurolysis, Neurolysis, Racz procedure Policy 7.01.73 (posted 1/15/19)
• Manipulation Under Anesthesia (MUA), Manipulation under Joint Anesthesia (MUJA), Manipulation Under Sedation (MUS) Policy 7.01.76 (posted 1/15/19)
• Minimally Invasive Techniques for Lumbar Interbody Fusion: Anterior Lumbar (ALIF), Axial Lumbar (AxiaLIF), Direct Lateral (DLIF), Extreme Lateral (XLIF), Laparoscopic Anterior Lumbar (LALIF), Posterior Lumbar (PLIF), Transforaminal Lumbar (TLIF) Policy 7.01.83 (posted 8/16/18)
• Orthotics (e.g., OttoBock E-Mag Active KAFO, OttoBock SensorWalk Electronic KAFO, MYOMO mPower 1000 arm brace) Policy 1.01.25 (posted 5/31/18)
• Osteochondral Grafting (Allograft, Autograft): Chondrofix®, Mosaicplasty, OATS Policy 7.01.59 (posted 8/16/18)
• Percutaneous Intradiscal Electrothermal Annuloplasty (IDET, IDTA, PIRFT, Biacuplasty) Policy 7.01.17 (posted 10/09/18)
• Percutaneous Vertebroplasty, Kyphoplasty, Mechanical Vertebral Augmentation (e.g., Kyphon Inflatable Bone Tamp) Policy 6.01.17 (posted 1/15/19)
• Prolotherapy (e.g., Sarapin) Policy 8.01.10 (posted 1/15/19)
• Radiofrequency Facet Denervation Policy 7.01.42 (posted 3/26/19)
• Sacroiliac Joint Fusion, IFUSE® Implant System ,SI-FIX, SImmetry® Sacroiliac Joint Fusion System, Silex™ Sacroiliac Joint Fusion System, SI-LOK® Sacroiliac Joint Fixation System Policy 7.01.93 (posted 1/15/19)
• Shoulder Arthroplasty Policy 7.01.95 (posted 3/26/19)
• Spinal Injections (Epidural and Facet Injectins) for Pain Management: Medial Branch Block Policy 7.01.87 (posted 1/15/19)
• Spinal Cord/Dorsal Column Stimulation Policy 7.01.51 (posted 2/06/19)
• Temporomandibular Joint (TMJ) Disease Policy 11.01.17 (posted 1/18/19)
• Total Hip Resurfacing, Metal-on-Metal Policy 7.01.74 (posted 1/15/19)
• Bone Growth Stimulators for the Appendicular Skeleton Policy 1.01.53 (posted 6/1/18)

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Cancer Treatment (Oncology)

• Cryosurgical Tumor Ablation Policy 7.01.03 (posted 5/31/18)
• Hyperthermia as a Cancer Treatment: Extracorporeal Whole Body, Intraperitoneal, Local, Regional, Whole Body Policy 2.01.25 (posted 6/12/18)
• Isolated Limb Perfusion and Infusion (Alkeran, L-PAM, Melphalan, Tumor Necrosis Factor) Policy 7.01.52 (posted 10/09/18)
• Peptide Receptor Radionuclide Therapy (PRRT, PRRNT): Receptor-Mediated Radiotherapy, Radiolabeled Nuclide Therapy, Somatostatin Analog, 90Y-DOTATOC, 177Lu-DOTA0, Tyr3, 90Y-DOTA0 Policy 7.01.78 (posted 10/02/18)
• Photodynamic Therapy (PDT) for Malignant Disease (Photofrin, Porfimer Sodium) Policy 8.01.06 (posted 3/26/19)
• Radiofrequency Tumor Ablation Policy 7.01.32 (posted 9/6/18)
• Radium-223 (Xofigo) for Treatment of Castration-Resistant Prostate Cancer Policy 6.01.44 (posted 5/31/18)
• Superficial Radiation Therapy for Treatment of Skin Cancers (Orthovoltage x-ray, SR-100, Xstrahl-100) Policy 6.01.43 (posted 5/31/18)
• Tumor-Treatment Field Therapy for Glioblastoma: Electrical Field Therapy, NovoTTF-100™ PDF Policy 6.01.45 (posted 5/31/18)

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Children's Health (Pediatrics)

• Cranial Orthotics/Helmet for Asymmetry (e.g., Dynamic Orthotic Cranioplasty, DOC) Policy 1.01.32 (posted 1/18/19)
• Developmental Evaluation and Testing Policy 2.01.54 (posted 4/4/18)
• Early Intervention Services Policy 10.01.09 (posted 11/26/18)
• Home Phototherapy for Hyperbilirubinemia (e.g., Biliblanket, Bili Lights) Policy 1.01.33 (posted 10/02/18)

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Chiropractic

• Chiropractic Care Policy 10.01.02 (posted 4/4/18)

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Cosmetic / Reconstructive Surgery

• Abdominoplasty and Panniculectomy (e.g., Belt Lipectomy, Lipectomy, Tummy Tuck) Policy 7.01.53 (posted 5/31/18)
• Alopecia (e.g., Areata, Androgenic, Scarring), Baldness, Hair Loss Policy 2.01.36 (posted 1/18/19)
• Blepharoplasty/Eyelid Surgery with or without Levator Muscle Advancement(Pseudoptosis Surgery, Ptosis Surgery, Brow Lift) Policy 7.01.55 (posted 5/31/18)
• Breast Reconstruction Surgery Policy 10.01.01 (posted 10/02/18)
• Cosmetic and Reconstructive Procedures: Acne Cysts, Actinic Keratoses, Collagen Injection, Complexion Analysis, Dermatoscopy, Drionic, Face Lift, Hairplasty, Hair Transplant, Hyperhydrosis, Iontophoresis, Labiaplasty, Liposuction, Prolaryn,Tattoos, Voice Lift, Benign Skin Lesion Removal, Skin Tag Removal, Keloid Scars, Chemical Peel, Dermabrasion, Port Wine Stains, Rosacea, Vitiligo Policy 7.01.11 (posted 4/4/18)
• Treatment of Hirsutism/ Hypertrichosis (Hair Removal) (e.g., Electrolysis, Epilation) Policy 2.01.38 (posted 1/18/19)
• Reduction Mammaplasty/ Breast Reduction Policy 7.01.39 (posted 10/02/18)
• Varicosities/Varicose Veins, Treatment Alternatives to Vein Stripping and Ligation (e.g., Ambulatory, Stab or Transilluminated Powered Phlebectomy, ClariVein®, Endoluminal Radiofrequency Ablation, Endovenous Embolization, Endovenous Laser Ablation, Mechanochemical Endovenous Ablation, MOCA, Sclerotherapy, Varithena™, VenaSeal™, VNUS) Policy 7.01.47 (posted 5/7/18)

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Dental

• Dental and Oral Care under Medical Plans: Bone Cysts, Odontogenic Cysts, Oral Surgery Policy 7.01.21 (posted 8/16/18)
• Dental Crowns and Veneers Policy 13.01.02 (posted 8/16/18)
• Dental Implants Policy 13.01.01 (posted 8/16/18)
• Dental Inlays and Onlays Policy 13.01.03 (posted 8/16/18)
• Periodontal Maintenance Policy 13.01.05 (posted 8/16/18)
• Periodontal Scaling and Root Planing Policy 13.01.04 (posted 8/16/18)

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Diabetes (Endocrinology)

• CGMS, Continuous glucose monitor, DexCom STS, Freestyle Navigator, Interstitial glucose monitoring, MiniMed CGMS® System Gold™, MiniMed Guardian® Real-Time, MiniMed Paradigm Revel® Real-Time system, DexCom G5®,Wrist glucose monitor, Continuous subcutaneous insulin infusion, CSII, Insulin pump therapy Policy 1.01.30 (posted 11/19/18)

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Digestive System (Gastroenterology)

• Colorectal Cancer Screening, Cologuard, CT Colonography, FIT, gFOBT, virtual colonoscopy, fecal DNA, fecal occult blood test Policy 2.01.51 (posted 6/12/18)
• Fecal Bacteriotherapy, Fecal microbiota therapy (FMT), Fecal transfusion, Fecal transplant, Human probiotic infusion (HPI), Intestinal Microbiotia Transplantation (IMT), Microbiome, Stool transplant Policy 2.01.48 (posted 10/09/18)
• Fecal Incontinence, Radiofrequency Treatment (Secca procedure) Policy 7.01.66 (posted 11/19/18)
• Gastric Electrical Stimulation and Gastric Pacing Policy 7.01.64 (posted 2/06/19)
• High Resolution Anoscopy (Anal Colposcopy) Policy 2.01.49 (posted 10/09/18)
• Magnetic Esophageal Ring for the Treatment of Gastroesophageal Reflux (GERD): Esophageal Sphincter Device, LINX™ System, Magnetic Sphincter Augmentation Policy 7.01.89 (posted 3/26/19)
• Plugs for Fistula Repair Policy 7.01.86 (posted 3/26/19)
• Surgical Management of Obesity: Adjustable Gastric Band, Bariatric Surgery, Biliopancreatic Diversion, Duodenal Switch, Endobarrier, Gastric Bypass, Gastric Plication, Imbrication, Lap Band, Restorative Obesity Surgery, Endoluminal [ROSE], Roux-en-Y, Sleeve Gastrectomy, Stomach Stapling, TOGA, Transoral or Vertical Banded Gastroplasty Policy 7.01.29 (posted 10/02/18)
• Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD): ELF, EndoCinch, Endoluminal Funcoplication, Endoluminal Gastroplication, Enteryx, EsophyX, Gatekeeper, Plexiglas Microspheres, NDO Plicator System, Radiofrequency Esophageal Treatment, Stretta Policy 7.01.45 (posted 6/12/18)
• Wireless Capsule Endoscopy/Imaging for Examination of the Gastrointestinal (GI) Tract: AGILE Patency Capsule, Given® Capsule Camera, PillCam SB, PillCam ESO Policy 6.01.27 (posted 9/6/18)

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Drug / Medications

• Collagenase Clostridium Histolyticum (Xiaflex) for Fibroproliferative Disorders Policy 5.01.15 (Posted 4/4/18)
• Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes Policy 7.03.03 (posted 6/12/18)

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Durable Medical Equipment & Supplies

• Augmentative and Alternative Communication Systems: AAC, Dynavox, Introtalker, VoiceMate, Walker Talker, Say-It-All, Speech Generating Devices (SGD) Policy 1.01.03 (posted 1/18/19)
• Breast Pumps Policy 1.01.39 (posted 5/31/18)
• Cervical Traction Devices (e.g., HomeTrac Deluxe, Saunders Cervical HomeTrac, Hydraulic, Over-The-Door, Pneumatic Cervical, Pronex) Policy 1.01.47 (posted 9/10/18)
• Continuous Passive Motion Device (CPM) in the Home Setting Policy 1.01.02 (posted 10/02/18)
• Durable Medical Equipment (DME) - Standard and Non-Standard, Home Medical Equipment Policy 1.01.00 (posted 10/02/18)
• Electrical Stimulation: Transcutaneous Electrical Nerve (TENS), Percutaneous Electrical Nerve (PENS), H-Wave and Interferential Stimulators (IFS), Percutaneous Neuromodulation Therapy, Bionicare® Policy 1.01.01 (posted 8/16/18)
• Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis: Triple Play VT®, Venodyne, VascuTherm2 Policy 1.01.51 (posted 9/6/18)
• Neuromuscular Electrical Stimulation (FNS, NMES, TES, VitalStim®) Policy 1.01.48 (posted 9/10/18)
• Pneumatic Compression Devices/Lymphedema Pump/Sleeve (e.g., Flexitouch™) Policy 1.01.17 (posted 5/31/18)
• Positive Airway Pressure Devices: CPAP, BiPAP, APAP, DPAP, C-FLex Policy 1.01.06 (posted 11/26/18)
• Standing Devices and Gait Trainers, Stander Policy 1.01.46 (posted 4/4/18)
• Surgical Stockings (e.g., Gradient Compression/GCS, Jobst, Sigvaris, TEDs) and Compression Garments (e.g., Arm Assist, Belisse Compressure Bra, Lymphedema, Mastectomy, Circaid, Juzo, Reid Sleeves) Policy 1.01.14 (posted 10/02/18)
• Vitrectomy Chair/ Face-Down Positioning System Policy 1.01.52 (posted 5/31/18)
• Wheelchairs and Power Operated Vehicles (POVs) (e.g., Scooters) Policy 1.01.16 (posted (posted 3/26/19)

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Ear, Nose & Throat (Otorhinolaryngology)

• Allergy Testing (Allergen Specific IgE, Allergen Specific IgG, Challenge, Cytotoxic, Dipstick, Disk, Intracutaneous, Intradermal, Leukocyte Histamine Release, Mucous Membrane, Paddle, Patch, Percutaneous, Phadiatop, Prick, Provocation-Neutralization, RAST, Rinkel, Scratch, Serial Endpoint Titration, Skin End Point Titration, Skin) Policy 2.01.10 (posted 2/06/19)
• Allergen Immunotherapy: Injections, Sublingual Immunotherapy Policy 2.01.11 (posted 10/09/18)
• Auditory Processing Disorder (APD) Testing Policy 2.01.39 (posted 1/18/19)
• Sinus Ostial Dilation for Treatment of Chronic Sinusitis (e.g., Balloon Sinuplasty), catheter sinusotomy Policy 7.01.85 (posted 6/12/18)
• Cochlear Implants and Auditory Brainstem Implants: Advanced Bionics® HiResolution Bionic Ear System (HiRes 90k), Cochlear® Nucleus 5, Med El® Maestro (Sonata or Pulsar), Nucleus 24® Auditory Brainstem Implant System, Nucleus® Hybrid™ L24 Cochlear Implant Policy 7.01.26 (posted 6/12/18)
• Implantable Bone Conduction Hearing Aids, Bone Anchored Hearing Aid (BAHA®), OBC bone anchored hearing aid system, Ponto Pro Policy 7.01.77 (posted 6/12/18)
• Posturography (e.g., Balance Test, Equitest) Policy 2.01.20 (posted 1/18/19)
• Treatment of Tinnitus: Habituation Therapy, Jastreboff Method, Masking, Retraining Therapy Policy 8.01.07 (posted 3/26/19)
• Sialendoscopy Policy 7.01.94 (posted 6/12/18)

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Environmental Health

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Eyes (Ophthalmology)

• Aqueous Drainage Devices (Stents and Shunts): Ahmed, Aquaflow, Baerveldt, CyPass, Ex-PRESS, Glaucoma Filtration Device, IOP, iStent, Krupin, Molteno, XEN Policy 9.01.18 (posted 5/31/18)
• Corneal Ultrasound Pachymetry Policy 9.01.07 (posted 5/31/18)
• Gas Permeable Scleral Contact Lens (e.g., Boston Ocular Surface Prosthesis, Prosthetic Replacement of the Ocular Surface Ecosystem [PROSE]) Policy 9.01.17 (posted 11/19/18)
• Intraocular Lens (IOL) Implants (e.g., Accommodating, Aspheric, Crystalens, Dynamic, Monofocal, Multifocal, Pseudoaccommodating) Policy 9.01.14 (posted 11/26/18)
• Intrastromal Corneal Ring Segments (ICRS) for Keratoconus (e.g., INTACS) Policy 9.01.13 (posted 6/12/18)
• Ophthalmologic Techniques for the Diagnosis of Glaucoma (Scanning Laser Polarimetry and Scanning Laser Ophthalmoscopy): GDx Imaging, Nerve Fiber Analysis, Heidelberg Retina Tomograph, Optomap Policy 9.01.06 (posted 1/15/19)
• Optical Coherence Tomography (OCT) for Ophthalmological Applications Policy 9.01.10 (posted 5/31/18)
• Photodynamic Therapy (PDT) for Subfoveal Choroidal Neovascularization (CNV) (e.g., Verteporfin, Visudyne) Policy 8.01.11 (posted 5/7/18)
• Phototherapeutic Keratoplasty/Keratectomy, PTK Policy 9.01.01 (posted 10/09/18)
• Refractive Procedures (e.g., Artisan, Astigmatic Keratotomy, Clear Lens Extraction, Photorefractive Keratectomy - PRK, INTACS - Corneal Ring Segments, Intracorneal Inlay, Laser-Assisted Subepithelial Keratomileusis - LASIK, Phakic Intraocular Lens) Policy 9.01.08 (posted 11/26/18)
• Transpupillary Thermotherapy (TTT) Policy 9.01.05 (posted 10/02/18)
• Vision/Eye Therapy: Optometric Phototherapy, Occlusion Therapy, Orthoptics, Pleoptics Policy 9.01.04(posted 3/26/19)
• Keratoprosthesis: AlphaCor™, BIOKOP, Boston type I, Boston type II, Dolhman-Doane, KPro, OOKP Policy #9.01.15 (posted 5/31/18)

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Feet (Podiatry)

• Foot Care and Treatment of Mycotic Nails Policy 2.01.35 (posted 10/02/18)
• Foot Orthotics, Arch Supports, Shoe Inserts Policy 1.01.41 (posted 10/02/18)

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Food (Nutrition)

• Enteral Formula/Nutrition, Enteral Therapy, Probiotics, Tube Feeding Policy 10.01.03 (posted 10/02/18)
• Nutritional Therapy Policy 8.01.18 (posted 4/4/18)
• Total Parenteral Nutrition (TPN), Intradialytic Parenteral Nutrition (IDPN), Intraperitoneal Nutrition (IPN), or Hyperalimentation Policy 11.01.04 (posted 10/02/18)

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Genetic Disease (Inherited Disease)

• Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/ Intellectual Disability or Autism Spectrum Disorder Policy 2.02.42 (posted 1/18/19)
• Gene Expression Analysis for Prostate Cancer Management: Oncotype DX® Prostate, Prolaris® Policy 2.02.48 (posted 3/26/19)
• Genetic Assay of Tumor Tissue to Determine Prognosis of Breast Cancer (Blueprint®, OncotypeDX™, MammaPrint®, Targetprint®) Policy 2.02.27 (posted 9/10/18)
• Genetic Testing for Hereditary BRCA Mutations: BART test, BRCA1, BRCA2, CHEK2 Policy 2.02.06 (posted 2/06/19)
• Genetic Testing for Cystic Fibrosis Policy 2.02.17 (posted 9/6/18)
• Genetic Testing for Familial Alzheimer's Disease Policy 2.02.16 (posted 9/10/18)
• Genetic Testing for Germline Mutations of the RET Proto Oncogene in Medullary Carcinoma of the Thyroid Policy 2.02.07 (posted 1/18/19)
• Genetic Testing for Hereditary Hemochromatosis Policy 2.02.05 (posted 10/09/18)
• Genetic Testing for Inherited Susceptibility to Colorectal Cancer: Familial Adenomatous Polyposis (FAP), Hereditary Nonpolyposis Colorectal Cancer (HNPCC), COLARIS® Policy 2.02.11 (posted 1/2/19)
• Genetic Testing for Inherited Disorders: Alpha-1-Antitrypsin Deficiency, ALS - Amyotrophic Lateral Sclerosis, Lou Gehrig's Disease, Angelman Syndromes, Becker Muscular Dystrophy, CADASIL, Charcot-Marie-Tooth Huntington's Disease, Congenital Adrenal Hyperplasia, Duchenne Muscular Dystrophy - DMD, Dystonia, Factor V, Fanconi Anemia, Fragile X syndrome, Gaucher Disease, Hemophilia A and B, Myotonic Dystrophy, Neurofibromatosis, Phenylketonuria - PKU, Prader Willi, Sickle Cell, Tay-Sachs Disease, Thalassemia Policy 2.02.03 (posted 8/16/18)
• Genetic Testing for Susceptibility to Hereditary Cancers (PTEN, Cowden Syndrome, TP53, Li Fraumeni Syndrome, BreastNext, CancerNext, OvaNext, MyRisk Hereditary Cancer, Melaris, Prolaris, Panexia) Policy 2.02.44 (posted 11/19/18)
• Genotyping Cytochrome P450 (CYP450) for Drug Metabolism: Amplichip Policy 2.02.30 (posted 3/26/19)
• Genotyping Cytochrome P450 2C9 (CYP2C9) and Vitamin K Epoxide Reductase Subunit CI (VKORC) That Affect Response to Warfarin (Coumadin®) Policy 2.02.33 (posted 1/18/19)
• Genotyping - Targeted Therapy for Non-Small Cell Lung Cancer (NSCLC) (e.g., EGFR, ALK and KRAS) Policy 2.02.35 (posted 3/26/19)
• Genotyping or Phenotyping for Thiopurine Methyltransferase (TPMT) for Patients Treated with Azathioprine (6-MP) Policy 2.02.37 (posted 2/06/19)
• Genotyping Uridine Diphosphate Glycuronosyltransferase (UGT1A1) for Patients Treated with Irinotecan Policy 2.02.34 (posted 1/18/19)
• Genetic Testing for Congenital Long QT Syndrome (Familion Test) Policy 2.02.38 (posted 9/10/18)
• Genotyping - KRAS Mutation Analysis in Metastatic Colorectal Cancer, BRAF, KRAS, NRAS, PIK3CA status, PTEN expression Policy 2.02.41 (posted 6/12/18)
• Molecular Markers in Fine Needle Aspirates of the Thyroid: Afirma® GEC, ThyroSeq® Policy 2.02.49 (posted 1/18/19)
• Molecular Panel Testing of Cancers to Identify Targeted Therapies, Molecular Panel Testing, Targeted Therapy, Foundation One, Caris Life Sciences, OmniSeq, PyroSeq Policy 2.02.51 (posted 1/18/19)
• Prenatal Genetic Testing: Preconception genetic testing, Preimplantation genetic diagnosis (PGD), Prenatal carrier screening Policy 4.01.03 (posted 5/7/18)
• Whole Exome and Whole Genome Sequencing for the Diagnosis of Genetic Disorders Policy #2.02.46 (posted 6/12/18)

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Heart & Blood Vessels (Cardiovascular)

• Ambulatory Event Monitor (AEM): Ambulatory Electrocardiographic (AECG) Devices, Cardiac Event Detection (CED), CardioNet, Mobile Cardiac Outpatient Telemetry (MCOT), Ziopatch Policy 2.01.03 (posted 10/02/18)
• Artificial Hearts: AbioCor, CardioWest Policy 7.01.65 (posted 8/16/18)
• Cardiac Resynchronization Therapy (Biventricular Pacemakers) for the Treatment of Heart Failure (Bioimpedance, Dual Chamber Pacemaker) Policy 7.01.58 (posted 10/02/18)
• Blood Pressure Monitoring, Automated, Ambulatory Policy 1.01.04 (posted 1/18/19)
• End-Diastolic Pneumatic Compression (e.g., Circulator) Boot Policy 1.01.31 (posted 5/31/18)
• Extracranial Carotid and Vertebral Artery Angioplasty and Stents (e.g., Percutaneous Transluminal Angioplasty, PTA) Policy 7.01.60 (posted 4/4/18)
• Home Automatic External Defibrillator (AEDs) and Wearable Defibrillator Vests (WCDs): HeartStart, LIFECOR Policy 1.01.42 (posted 5/7/18)
• Implantable Cardiac Hemodynamic Monitoring for Heart Failure: CardioMEMS HF, Pulmonary artery pressure sensor, Wireless hemodynamic monitor Policy 7.01.91 (posted 10/09/18)
• Implantable Cardioverter-Defibrillator (AICD, Automatic ICD, Biventricular ICD, Dual-Chamber ICD, ICD) Policy 7.01.06 (posted 4/4/18)
• Intravascular Ultrasound (IVUS) Policy 6.01.09 (posted 9/6/18)
• MAZE Procedures for Atrial Fibrillation and Flutter (e.g., Convergent procedure, COX III, Epicardial Maze, Hybrid, Mini Maze, Pulmonary Vein Isolation, Thoroscopic off-pump surgical ablation [TOPS]) Policy 7.01.27 (posted 2/16/18)
• Microvolt T-Wave Alternans Policy 2.01.45 (posted 5/7/18)
• Noninvasive Measurement of Cardiac Bioimpedance: Impedance Cardiography (ICG), Thoracic Electrical Bioimpedance (TEB) Policy 6.01.26 (posted 11/19/18)
• Percutaneous Left Atrial Appendage Closure Devices: Amplatzer® Amulet, Amplatzer® cardiac plug, Implantable hemodynamic monitor, Lariat®, PLAATO, Watchman™ Policy 7.01.92 (posted 1/2/19)
• Signal Averaged Electrocardiogram (SAECG) Policy 2.01.02 (posted 2/06/19)
• Surgical Ventricular Reduction (e.g., Partial Ventriculectomy, Batista Procedure) Policy 7.01.31 (posted 5/31/18)
• Surgical Ventricular Restoration (SVR): DOR Procedure, Surgical Anterioe Endocardial Restoration (SAVER), Ventricular Remodeling Policy 7.01.71 (posted 11/19/18)
• Transcatheter Closure Devices for Cardiac Defects: Amplatzer Septal Occluder, Angel Wing Device, Atrial Septal Detect Occluding System (ASDOS), CardioSEAL, HELEX, Sideris Buttoned Device Policy 7.01.34 (posted 4/4/18)
• Transmyocardial Revascularization (TMR), Percutaneous Transmyocardial Revascularization (PTMR) Policy 7.01.12 (posted 3/26/19)
• Ventricular Assist Devices (VAD, LVAD) Policy 7.01.07 (posted 8/16/18)

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Home Care

• Home Exercise/Physical Therapy Equipment (e.g., Home Gym, Jacuzzi) Policy 1.01.12 (posted 1/18/19)
• Home and Community Oxygen Therapy: Long Term Oxygen Therapy (LTOT), High Altitude Stimulation Test (HAST), Oxygen Concentrator, Portable Oxygen Policy 1.01.05 (posted 9/10/18)
• Home Prothrombin Time Monitor (e.g., Acusure™, CoaguChek®, International Normalized Ratio [INR], Prothrombin Time [PTT], Protime, Rubicon®) Policy 1.01.44 (posted 8/16/18)
• Patient Lifts (e.g., Hoyer, Saralift), Seat Lift Chair Mechanisms and Ceiling Lifts Policy 1.01.08 (posted 8/16/18)
• Telemedicine and Telehealth Policy 1.01.49 (posted 1/18/19)

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Lab Tests (Pathology)

• Anticoagulation Testing Policy 2.02.40 (posted 9/6/18)
• Biochemical Markers of Bone Turnover (e.g., Collagen Cross Links, Cross Laps, ITCP, N-telopeptides, NTx, Pyrilinks) Policy 2.02.18 (posted 9/6/18)
• Cardiovascular Disease Risk Assessment - Laboratory Evaluation of Lipids: Apolipoprotein A-1, B, and E, Lipoprotein (a) Enzyme Immunoassay Policy 2.02.29 (posted 1/18/19)
• First Trimester Screening for Down Syndrome (e.g., Cell-Free Fetal DNA, Harmony™, Free Beta PAPP-A, MaterniT21™, Non-invasive Prenatal Testing, Nuchal Translucency, Panorama™, Verify®) Policy 2.02.25 (posted 9/10/18)
• Inflammatory Markers of Coronary Artery Disease Risk (High Sensitivity C-Reactive Protein, HS-CRP, Lipoprotein-Associated Phospholipase A2, Lp-PLA2, PLAC) Policy 2.02.15 (posted 8/16/18)
• Her-2 Testing in Invasive Breast Cancer Using Fluorescence in Situ Hybridization (FISH) or Immunohistochemistry (IHC) Assays: HercepTest, PathVysion, INFORM®, FISH pharmdX Policy 2.02.31 (posted 5/7/18)
• Measurement of Serum Antibodies to Infliximab and Adalimumab: Anser™IFX, Anser™ADA Policy 2.02.47(posted 1/18/19)
• Non-Invasive Helicobacter Pylori (H Pylori) Testing: HpSA, Urea Breath Test Policy 2.02.02 (posted 6/12/18)
• Pathfinder TG® Molecular Testing: Redpath, Topographic Genotyping Policy 2.02.39 (posted 2/06/19)
• Proteomics-Based Testing for the Evaluation of Ovarian (Adnexal) Masses: Ova1™ Policy 2.02.43 (posted 11/19/18)
• Tumor Chemoresistance and Chemosensitivity Assays: Cytoprint, EDR Assay, Extreme Drug Resistance Assay, Histoculture Drug Response Assay Policy 2.02.32 (posted 8/16/18)
• Screening for Vitamin D Deficiency Policy 2.02.45 (posted 9/6/18)
• Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease, Anti-neurtrophil Cytoplasmic Antibodies, ANCA, ASCA, Serological markers Policy 2.02.19 (posted 3/26/19)
• Serum Tumor Markers for Diagnosis and Management of Cancer (AFP, CA-125, CA-19-9, CA-15-3, CA 27, CA 29, CEA, HCG, Proteomic) Policy 2.02.10 (posted 10/09/18)
• Urinary Tumor Markers for Bladder Cancer: AccuDx, BTA Stat™, Fibrin/Fibrinogen Degradation Products (FDP), ImmunoCyt, Nuclear Matrix Protein (NMP-22), Urinary Bladder Cancer Antigen (UBC Rapid Test) Policy 2.02.12 (posted 9/6/18)
• Urine Drug Testing Policy 2.02.50 (posted 2/06/19)

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Lungs (Respiratory)

• Airway Clearance Devices: Oscillatory Devices - ABI Vest, Acapella, Flutter Valve, Lung Flute®, ThAIRapy Vest; Mechanical Percussors and Assisted Cough Devices - Cofflator, Cough-Alator, In-Exsufflator Policy 1.01.15 (posted 1/18/19)
• Bronchial Thermoplasty (e.g., Alair® System) Policy 7.01.88 (posted 2/06/19)
• Electromagnetic Navigation Bronchoscopy (ENB) Policy 6.01.40 (posted 2/06/19)
• Measurement of Exhaled Markers of Airway Inflammation in Patients with Asthma: Exhaled Breath Condensate, Exhaled Nitric Oxide, Nioxx Policy 2.01.41 (posted 2/06/19)
• Oral Appliances for the Treatment of Sleep Related Breathing Disorders: Mandibular Repositioning Device, Nocturnal Airway Patency Appliance (NAPA), Tongue Retaining Device Policy 1.01.07 (posted 4/4/18)
• Surgical Management of Sleep Disorders/Sleep Apnea: Airvance®, Atrial overdrive pacing, Aura6000 System, CAPSO, Encore™, HGNS®, Hypoglossal Nerve Stimulation, Inspire II Upper Airway Stimulation System, LAUP, Pillar™, Repose™, Snoreplasty, Somnoplasty, UPPP Policy 7.01.41 (posted 5/31/18)

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Miscellaneous

• Ambulance: Air Policy 11.01.06 (posted 6/1/18)
• Ambulance: Land/Ground Policy 10.01.07 (posted 6/1/18)
• Bioimpedance Devices for Detection and Management of Lymphedema, bioelectrical impedance spectroscopy Policy 2.01.52 (posted 6/12/18)
• Clinical Trials Policy 11.01.10 (posted 1/18/19)
• Comfort, Convenience, Custodial or Cosmetic Services Policy 11.01.11 (posted 1/18/19)
• Disability Determination for Extension of Benefits after Contract Termination Policy 10.01.11 (posted 10/09/18)
• Emergency Care Services Policy 10.01.12 (posted 5/31/18)
• Experimental or Investigational Services Policy 11.01.03 (posted 9/10/18)
• Gender Reassignment Surgery: Gender Dysphoria, Gender Identity Disorder (GID), Genital Correction Surgery, Genital Reassignment Surgery, Genital Reconstruction, Gender Realignment Surgery, Gender Confirmation Surgery, Intersex, Transsexualism, Transsexual Surgery Policy 7.01.84 (posted 8/16/18)
• Handicapped Dependent Coverage Policy 10.01.08 (posted 11/26/18)
• Hyperbaric Oxygen Therapy (HBOT): Systemic or Topical, Topical Oxygen Wound Therapy (TOWT) Policy 2.01.07 (posted 3/26/19)
• Interfacility (Hospital-to-Hospital, Inpatient, Interhospital) Transfer of a Registered Inpatient Policy 11.01.18 (posted 5/31/18)
• Medical Response to Contamination from Terrorist Attacks: Biological (e.g., Anthrax, Germ Warfare, Plague, Smallpox), Chemical, Radiation Policy 11.01.09 (posted 10/02/18)
• Medical/Non-Surgical Weight Management Programs and Services, Indirect Calorimetry, Intensive/high intensity lifestyle counseling program Policy 11.01.01 (posted 1/18/19)
• Medically Necessary Services Policy 11.01.15 (posted 1/18/19)
• Out of Area/Out of Network Services Policy 11.01.14 (posted 5/31/18)
• Private Rooms Policy 12.01.06 (posted 3/26/19)
• Second Medical and Second Surgical Opinions, Confirmatory Consultation Policy 10.01.10 (posted 5/31/18)
• External Prosthetic Devices: C-leg, Intelligent prosthesis, microprocessor-controlled lower limbs, Ossur Rheo, Vacuum-assisted-socket system (VASS) Policy 1.01.18 (posted 10/09/18)
• Skilled Nursing Facility (SNF) Care for Medicare Advantage Members Policy 11.01.21 (posted 5/31/18)

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Nervous Systems (Neurology)

• Angioplasty of Intracranial Atherosclerotic Stenoses with or without Stenting (e.g., Percutaneous Transluminal Angioplasty, Neurolink® System, Wingspan™ Stent) Policy 7.01.70 (posted 3/26/19)
• Deep Brain Stimulation Policy 7.01.23 (posted 5/31/18)
• Endovascular Repair (Coil Embolization) of Intracranial Aneurysms - Enterprise Stent, Guglielmi Coil, Neuroform Stent, Pipeline Embolization Device (PEI), Transcatheter Intracranial Embolization Policy 7.01.81 (posted 6/12/18)
• Endovascular Treatment of Acute Ischemic Stroke - Mechanical Embolectomy, Merci Retriever, Penumbra, Percutaneous Transluminal Angioplasty, Solitaire, Trevo® Policy 7.01.82 (posted 9/6/18)
• Evoked Potentials: Auditory, Brainstem Auditory, Somatosensory, Visual and Intraoperative Monitoring of Evoked Potentials Policy 2.01.27 (posted 2/16/18)
• Neuropsychiatric Quantitative Encephalography in the Diagnosis of Attention Deficit/Hyperactivity Disorder (e.g., NEBA system) Policy 2.01.53 (posted 5/7/18)
• Neuropsychological Testing Policy 2.01.50 (posted 1/18/19)
• Percutaneous Posterior Tibial Nerve Stimulation (PPTNS) Policy 8.01.22 (posted 5/31/18)
• Quantitative Sensory Testing (QST) Policy 2.01.34 (posted 10/09/18)
• Sacral Nerve Stimulation for Pelvic Floor Dysfunction (Incontinence, Neuromodulation, Urinary Retention) Policy 7.01.10 (posted 2/16/18)
• Vagus Nerve Stimulation Policy 7.01.05 (posted 10/02/18)

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Radiation Treatment

• Brachytherapy after Breast Conserving Surgery, as Boost with Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation: Accelerated Partial Breast Irradiation, APBI, Axxent, MammoSite Policy 6.01.30 (posted 1/2/19)
• Brachytherapy or Radioactive Seed Implantation for Prostate Cancer Policy 6.01.16 (posted 11/19/18)
• Intensity Modulated Radiation Therapy (IMRT) Policy 6.01.24 (posted 10/02/18)
• Intravascular Brachytherapy, Endovascular Radiation Policy 6.01.15 (posted 9/6/18)
• Proton Beam Radiation Therapy (Charged Particle, Conformal) Policy 6.01.11 (posted 9/10/18)
• Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors (SIR-Spheres, Theraspheres) Policy 7.01.69 (posted 9/6/18)
• Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy (e.g., CyberKnife, Gamma Knife Radiosurgery, Linear Accelerator, Linac) Policy 6.01.12 (posted 9/10/18)

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Radiology (x-rays) & Imaging

• Bone Densitometry/Bone Density Studies: DEXA Scan, Dual Photon Absorptiometry (DPA), Morphometric X-ray Absorptiometry, Single Photon Absorbtiometry (SPA), Ultrasound Measurement of the Heel Policy 6.01.05 (posted 10/09/18)
• Cardiac Computed Tomographic Angiography (Calcium Scoring, Cardiac/Coronary CTA, Coronary Artery CTA, CT Angiography) Policy 6.01.34 (posted 8/16/18)
• Coronary Calcium Scoring : Electron Beam CT (EBCT), Helical CT, Spiral CT, Multidetector Row CT (MDCT), Ultrafast CT, Cardiac Calcium Scoring Policy 6.01.13 (posted 3/26/19)
• CT (Computed Tomography) Perfusion Imaging - Dynamic Perfusion CT, Multimodal CT, Perfusion CT, Xenon-enhanced CT (XeCT) Policy 6.01.37 (posted 4/4/18)
• Magnetic Resonance Imaging (MRI) of the Breast (Breast MRI, CAD MRI) Policy 6.01.35 (posted 8/16/18)
• Magnetic Resonance Imaging Prostate Multiparametric MRI Policy 6.01.46 (posted 8/16/18)
• Magnetic Resonance Spectroscopy (MRS) Policy 6.01.03 (posted 3/26/19)
• Mammography: Compuer Aided Detection (CAD): Image Checker System, MammoReader, R2 Checker, Second Look, RapidScreen Policy 6.01.23 (posted 10/02/18)
• Mammography: Digital Breast Tomosynthesis Policy 6.01.22 (posted 9/10/18)
• Positron Emission Tomography (PET) Cardiac Applications Policy #6.01.41 (posted 4/4/18)
• Positron Emission Tomography (PET) Non-Oncologic Applications (FDG PET) Policy 6.01.07 (posted 4/4/18)
• Positron Emission Tomography (PET), Oncologic Applications (FDG PET, FDG SPECT) Policy 6.01.29 (posted 11/19/2018)
• Nuclear Breast Imaging: Breast Specific Gamma Camera, BSGI, Gammagram, Miraluma, Radioimmunoscintigraphy, Scintigraphy, Scintimammography Policy 6.01.02 (posted 4/4/18)
• Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening: Electron Beam Computed Tomography (EBCT), Helical CT, Low-Dose CT, Spiral CT Policy 6.01.19 (posted 2/06/19)
• Transcranial Doppler Ultrasound Policy 6.01.18 (posted 1/18/19)

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Skin (Dermatology)

• Bioengineered Tissue Products (Affinity™, AlloDerm®, AlloMax™, AlloSkin™, AlloWrap™, AmnioBand™, Amnioexcel®, AmnioMatrix®, Apligraf®, Artacent™ Wound, ArthroFlex™, Artificial skin, Avaulta Plus™, Biobrane®, Biobrane l®, Bioengineered skin, Biologic tissue, Biovance®, Clarix® Flo, Collamend, Conexa™, Cygnus Solo™, Cygnus Matrix™, Cygnus Max™, Cymetra®, Cytal™ Burn Matrix, Cytal™ Wound Matrix, DermACELL AWM™, DermaMatrix, DermaPure™, DermaSpan™, Dermavest™, Endoform Dermal Template™, ENDURAgen™, Epicel®, EpiCord™, EpiFix, Excellagen®, E-Z Derm™, FlexHD®, GammaGraft, Grafix® CORE, Grafix® PRIME, GraftJacket®, GraftJacket® Xpress, Graftskin, Guardian, hMatrix®, Hyalomatrix®, Integra™, Integra™ Bilayer Wound® Matrix, Integra™ Dermal Regeneration Matrix®, Integra™ Flowable Wound® Matrix, InteguPly™, Interfyl™, Laserskin, MariGen, Mediskin®, Miroderm®, Neoform, Neox®, Neox 1K, Neox® Flo, NuShield™, OASIS® Wound Matrix, OASIS® Burn Matrix, OASIS® Ultra, Omnigraft™, Orcel™, Orthoadapt, PalinGen® - Membrane, Hydromembrane, Flow, and SportFlow, Pelvicol, Pelvisoft, Permacol™, Primatrix, PuraPly, Restore, Revitalon™, Skin substitute, StrataGraft, Strattice™, SurgiMend®, TenSIX™, TheraSkin®, Tissuemend, TransCyte™, TranZgraft, TruSkin™, Veritas® Collagen Matrix, XCM Biological Tissue Matrix.) Policy 7.01.35 (posted 9/10/18)
• Extracorporeal Photochemotherapy/Photopheresis Policy 8.01.01 (posted 1/2/19)
• Growth Factors for Wound Healing and Other Conditions: Becaplermin, Platelet Derived Growth Factor (PDGF), Platelet Rich Plasma, Regranex Policy 2.01.24 (posted 3/26/19)
• Light and Laser Therapies for Dermatologic Conditions (BCLear Lamp, CureLight Broadband, Excilite Lamp, Levulan®, Kerastick®, Metvix®, Narrow Band Ultraviolet B, Psoralens, PUVA, Ultraviolet Light, UVA, UVB, VTRAC Lamp, XeCL, XTRAC) Policy 8.01.21 (posted 1/2/19)
• Negative Pressure Wound Therapy, PICO™ system, SNaP® system, Topical Negative Pressure therapy, Vacuum Assisted Closure therapy Policy 1.01.38 (posted 1/2/19)

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Therapy & Rehabilitation

• Cardiac Rehabilitation Policy 8.01.14 (posted 8/16/18)
• Cognitive Rehabilitation, Attention Rehabilitation, Sensory Integration Therapy Policy 8.01.19 (posted 8/16/18)
• Occupational Therapy (OT): Constraint Induced Movement Therapy (CIMT), Gait Analysis, Sensory Integration Therapy, SIT Policy 8.01.17 (posted 10/02/18)
• Physical Therapy (PT) Policy 8.01.12 (posted 10/02/18)
• Speech/Language Pathology and Therapy (e.g., Fast ForWord, Lee Silverman Voice Therapy [LSVT-LOUD™], Voice Therapy) Policy 8.01.13 (posted 11/26/18)

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Transplants

• Allogeneic Hematopoietic Stem Cell Transplantation Policy 7.02.02 (posted 1/2/19)
• Autologous Hematopoietic Stem Cell Transplantation Policy 7.02.03 (posted 1/2/19)
• Heart and Heart/Lung Transplants Policy 7.02.06 (posted 5/7/18)
• Kidney (Renal) Transplantation Policy 7.02.04 (posted 5/7/18)
• Liver/Hepatic Transplantation Policy 7.02.07 (posted 2/06/19)
• Lung and Lobar Lung Transplant Policy 7.02.10 (posted 5/7/18)
• Pancreas Transplant (Pancreas Transplant Alone, Pancreas After Kidney Transplant, Simultaneous Pancreas Kidney Transplant); Islet Cell Transplant Policy 7.02.01 (posted 2/06/19)
• Placental and Umbilical Cord Blood as a Source of Stem Cells Policy 7.01.48 (posted 9/6/18)
• Small Bowel and Multivisceral Transplants in Adults and Children Policy 7.02.05 (posted 5/7/18)

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Urinary System (Genitourinary)

• Cryosurgery for Prostate Cancer Policy 7.01.01 (posted 9/6/18)
• Erectile Dysfunction: Caverject, Edex, ErecAid, Intracavernosal Therapy, Intraurethral Therapy, MUSE (Medicated Urethral System for Erection), Penile Prosthesis, Penile Vein Ligation, Vacuum Erection Device, Vascular Revascularization Policy 7.01.30 (posted 10/02/18)
• Pelvic Floor Electrical Stimulation (PFES) as a Treatment of Urinary or Fecal Incontinence, Intravaginal Stimulation Policy 1.01.19 (posted 9/6/18)
• Prostate Cancer Screening, Detection and Monitoring (e.g., Digital Rectal Exam - DRE, PCA3Plus, Prostate Specific Antigen - PSA, Prostatic Acid Phosphatase - Male PAP Test) Policy 10.01.05 (posted 1/2/19)
• Transurethral Microwave Thermotherapy (TUMT) of the Prostate (e.g., Prostatron, Targis, Urowave System, CoreTherm, Prolieve, TMx-2000) Policy 7.01.28 (posted 1/18/19)
• Bulking Agents for Treatment of Urinary or Fecal Incontinence (Bovine Collagen, Carbon Coated Beads, Coaptite®, Contigen®, Durasphere, GAX, Macroplastique®, Microballoons, Solesta, Teflon® Injections, Uryx®) Policy 7.01.22 (posted 6/12/18)

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Vaccines (Immunizations)

• Immunizations/Vaccines (e.g., Hepatitis A, Hepatitis B, Human Papillomavirus [HPV, Cervarix, Gardasil], Meningococcal, Pneumoccal [Pneumovax 23, Prevnar], Rotavirus [Rotarix], Varicella [Varivax], Varicella Zoster [Zostavax]) Policy 2.01.42 (posted 10/09/18)

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Women's Health (Obstetrics & Gynecology)

• Assisted Reproductive Technologies (ART) for Infertility): COMET Assay, Hylaluronan Binding Assay (HBA), Sperm DNA Integrity, Sperm Chromatin Structure Assay (SCSA®), Sperm DNA Fragmentation Assay (SDFA™), TUNEL Assay, Artificial or Intrauterine Insemination (AI, IUI), Microsurgical Epididymal Sperm Aspiration (MESA), Microsurgical Testicular Sperm Extraction (MicroTESE), Testicular Sperm Extraction (TESE), Direct Intra-Peritoneal Insemination (DIPI), Gamete Intrafallopian Transfer (GIFT), Intracytoplasmic Sperm Injection (ICSI), In-vitro Fertilization (IVF), Zygote Intrafallopian Transfer (ZIFT) Policy 4.01.05 (posted 11/26/18)
• Cervical Cancer Screening and Human Papilloma Virus (HPV) Testing (e.g., Cervista™, Cobas® HPV test, DNA with PAP, HPV, HPV DNA testing, Human Papillomavirus, HC 2, Hybrid Capture 2, Pap/ Papanicolaou smear: Direct visualization, Monolayer, Optical; FocalPoint™, MonoPrep Pap Test (MPPT), PapSure®, Speculite®, Speculoscopy, SurePath, ThinPrep®) Policy 2.02.04 (posted 11/26/18)
• Endometrial Ablation: Her Option™, Hydro ThermAblator®, MEA System, Novasure™, Resectoscope, Rollerball, ThermaChoice®, Thermal Balloon Therapy Policy 4.01.01 (Posted 3/26/19)
• Female Sterilization (e.g., Adiana®, Essure®, Tubal Ligation) Policy 4.01.07 (posted 11/26/18)
• Home Birth by Certified Nurse Midwives Policy 11.01.23 (posted 11/26/18)
• Obstetrical Ultrasound in the Second Trimester Policy 6.01.42 (posted 8/16/18)
• Uterine Artery Occlusion in the Treatment of Uterine Fibroids: Uterine Artery/Fibroid Embolization (UAE/UFE), Uterine Artery Coagulation Policy 4.01.04 (posted 3/26/19)