A
Adenotonsillectomy 130
Allergy Testing and Treatments 217
Allogeneic Hematopoietic Stem Cell Transplantation for Genetic Diseases and Acquired Anemias 190
Allogeneic Stem Cell Transplants 092
Alpha Index, Medical Policy 505
Ambulatory Surgical Procedures 389
Amegakaryocytic Thromocytopenia 092
Analysis of Proteomic Patterns 366
Angiotensin II Receptor Antagonists 012
Anterior Eye Segment Optical Imaging 084
Anti-CCP testing for rheumatoid arthritis 142
Aqueous Shunts and Devices for Glaucoma 223
ART, Assisted Reproductive Technologies 086
Assays of Genetic Expression in Tumor tissue: Techniques to Determine prognosis of Breast Cancer 055
Assist Devices, Ventricular 388
Assisted Reproductive Technologies 086
Audiometric Test, Hearing Test 425
Auditory Evoked Potentials 211
Autologous Bone Marrow Transplant 126
Autologous Chondrocyte Implantation 374
Autologous Hematopoietic Stem Cell Transplantation for Malignant Astrocytomas and Gliomas 159
Autologous Progenitor Cell Therapy 424
Autologous Stem Cell Transplant 126
Automated Lamellar Keratoplasty 241
Automated Percutaneous Discectomy 231
Automated Point of Care Nerve Conduction Tests 222
B
B-Type Natriuretic Peptide 031
Beksey Audiometry, Hearing Test 425
Benign Prostatic Hyperplasia 040
Biofeedback as a Treatment of Chronic Pain 210
Biofeedback as a Treatment of Urinary Incontinence 173
Biofeedback as Psychotherapy 423
Biofeedback for Miscellaneous Indications 187
Biofeedback for the Treatment of Headache 152
Bisphosphonates, Infusion-Injection 061
Biventricular Pacemakers for the Treatment of Congestive Heart Failure 101
Bone Marrow Transplants-Allo 092
Bone Marrow Transplants-Auto 126
Bone Morphogenetic Protein 097
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds 175
C
Cancer Therapy, Isolated Limb Perfusion 124
Cancer, Breast Mammography 125
Cancer, Monoclonal Antibody Imaging 378
Candida Hypersensitivity Test 217
Carbohydrate Cancer Antigens 167
Catheter Ablation of Arhythmogenic Foci 123
Cautery-assisted Palatal Stiffening Procedure 130
Chemotherapy, Intra-Arterial 369
Cinryze (C1 Inhibitor (Human)) 112
Closure Devices for Patent Foramen Ovale 121
CNS stimulants and psychotherapeutic agents 019
Cochlear Implants for Deafness 087
Collagen Meniscus Implants 110
Colorectal Cancer Screening 365
Complications of a Noncovered Service 089
Computerized Tomography (CT) Scans 009
Conductive Keratoplasty (CK) 241
Conjunctival Challenge Test 217
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 107
Corneal Endothelial Microscopy 050
Cox II Inhibitor Drugs Authorization Form 432
CPM, Continuous Passive Motion 128
Cryosurgical Ablation of the Prostate 149
CVS, Chorionic Villus Sampling 216
Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy 048
D
Destruction of Macular Drusen by Photocoagulation 241
Detection of Circulating Tumor Cells in the Management of Patients with Cancer 265Detoxification for Allergies 217
Diabetes Step Therapy - Second Step Agents 041
Diabetics, Foot Care Services 385
Diagnosis and management of Idiopathic Environmental Intolerance (Clinical Ecology) 264
Dopamine Agonists, non-ergot derived 119
Drug Eluting Coronary Stents 424
Drug Management & Prior Authorization 251
Drugs, Antihyperlipidemics 013
Drugs, B-Type Natriuretic Peptide 031
Drugs, Bisphosphonate, Oral 058
Drugs, Colony Stimulating Factors 337
Drugs, IgE Receptor Binding Inhibitors 017
Drugs, Macrophage Colony Stimulating Factors 337
Drugs, Medicare HMO/PPO Blue Non-covered List 023
Drugs, Pregabalin (Lyrica) 057Dual-Energy X-ray Absorptiometry 034
Dynamic Spinal Visualization 195E
ECMO: Extracorporeal Membrane Oxygenation 131
ECT, Electroconvulsive Therapy 319
EECP, Enhanced External Counterpulsation 388
Electrical Bone Growth Stim 157
Electrical Stimulators, Brain 083
Electrical Stimulators, Cerebellar 083
Electrical Stimulators, PENS 172
Electrical Stimulators, Spine 083
Electrical Stimulators, TENS 003
Electrical Stimulators, Vagal 083
Electromagnetic Navigation Bronchoscopy 203
Electrostimulation Therapy 435
End Diastolic Pneumatic Compression Boots 388
Endobronchial Brachytherapy 091
Endometrial Ablation and Robotic Assisted Myomectomy 331
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus 218
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA) 098
Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections 233
Enhanced External Counterpulsation 388
Enzyme Potentiated Immunotherapy 217
Epidermal Growth Factor Receptor (EGFR) Inhibitors 114
ERCP with Laser or Electrohydraulic Lithotripsy 209
Extracorporeal Membrane Oxygenation 131
Extracorporeal Photopheresis 051
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 081
F
Fentanyl, oral-transmucosal 113
Fetal Mesencephalic Transplant 361
Follicular Non-Hodgkin's Lymphoma 092
G
Gamma interferon blood test 383
Garren-Edwards Gastric Bubble 379
Gastroesophageal Reflux Surgeries 376
Gaucher's Disease, Ceredase 317
Genetic Testing for Congenital Long QT Syndrome 082
Genetic Testing for Tamoxifen Treatment 067
Genetic Testing for Warfarin Dose 214
Globulin, Respiratory Syncytial Virus Immune 422
Granulocyte Colony Stimulating Factors 337
Granulocyte-Macrophage Colony Stimulating Factors 337
H
Hair Prostheses & transplants 068
Heart-Lung Transplantation 269
HeartmateTM Heart Assist Device 388
Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia 076
Hematopoietic Stem cell Transplantation for Acute Myeloid Leukemia 150
Hematopoietic Stem Cell Transplantation for Autoimmune Diseases 192
Hematopoietic Stem Cell Transplantation for Breast Cancer 213
Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia 212
Hematopoietic Stem Cell Transplantation for CNS Embryonal Tumors and Ependymoma 205
Hematopoietic Stem Cell Transplantation for Epithelial Ovarian Cancer 204
Hematopoietic Stem Cell Transplantation for Hodgkin Lymphoma 207
Hematopoietic Stem Cell Transplantation for Miscellaneous Solid Tumors in Adults 191
Hematopoietic Stem Cell Transplantation for Multiple Meyloma 075
Hematopoietic Stem Cell Transplantation for Non-Hodgkin Lymphomas 143
Hematopoietic Stem cell Transplantation for Primary Amyloidosis or Waldenstrom Macroglobulinemia 181
Hematopoietic Stem Cell Transplantation for Solid Tumors of Childhood 208
Hemotopietic Stem Cell Transplantation in the Treatment of Germ Cell Tumors 247
High-Sensitivity C-Reactive Protein 032
High-Speed CT for Heart Disease and Screening for Lung Cancer 355
Home Infusion Therapy, Prior Authorization Guideline 430
Home Total Parenteral Nutrition 296
Horizontal Gastric Partitioning 379
Human Anti-hemolytic Factor 360
Hyalgan® (Sodium Hyaluronate) 427
Hyroid Suspension 130
I
IgE Receptor Binding Inhibitors 017
Imaging, Monoclonal Antibody 378
Immune Cell Function Assay in Solid Organ Transplantation 182
Immune Globulin, Respiratory Syncytial Virus 422
Immunochemical Fecal Occult Blood Testing 135
Immunotherapy, Paternal/Fetal 387
Implantable Ambulatory Event Monitors 347
Implantable Cardioverter Defibrillator 070
Implantation of Intrastromal Corneal Ring Segments 235
Implantation of Palatal Implants 130
Index, Medical Policy 505
Infantile Malignanct Osteoporosis 092
Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates 100Injectable Clostridial Collagenase for Fibroproliferative Disorders 225
Injections for osteoarthritis 427
Intensity Modulated Radiation Therapy of the Prostate 090
Intracoronary Brachytherapy 424
Intradiscal Electrothermal Therapy (IDET) 099
Intradiscal Radiofrequency Thermocoagulation 099
Intraepidermal Nerve Fiber Density 234
Intrahepatic Portosystemic Shunt 370
Intraoperative Motor Evoked Potentials 211
Intraoperative Radiation Therapy 278
Intraoperative Somatosensory Evoked Potentials 211
Intraoperative Visual Evoked Potentials 211
Intrastromal ring segments 241
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 171
Intravenous Immunoglobulin 310
Iontophoresis, Phonophoresis 095
Isolated Limb Perfusion/Infusion for Malignant Melanoma 124
Isolated Small Bowel Transplant, Small Bowel/Liver and Multi-vissceral Transplant 368J
K
Keratectomy, Photorefractive 241
Kidney-Pancreas Transplant 328
KRAS Mutation Analysis in Metastatic Colorectal Cancer 104
KRAS Mutation Analysis in Non-Small Cell Lung Cancer (NSCLC) 194L
Laboratory Testing for HIV Tropism 008
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids 244
Laser Ablation of Varicose Veins 045
Laser for Port Wine Stains 068
Laser-assisted Uvuloplatoplasty (LAUP) 130
Leukocyte Histamine Release 217
Liver/Intraarterial Chemotherapy 369
Lobar Lung Transplantation 015
Lombard Test, Hearing Test 425
M
Magnetic Resonance MRI, MRA, MRV, MRS 106
Magnetic Resonance Imaging to Monitor Integrity of Gel Filled Breast Implants 139
Magnetoencephalography-Magnetic Source Imaging 137
Mammography and Scintimammography 125
Managed Care, Indemnity and PPO Guidelines Processing Information 812Mandibular or Maxillary Surgery 293
Manipulation under Anesthesia for Treatment of Chronic Spinal or Pelvic Pain 099
Maxillofacial Surgery including Mandibular or Maxillary Advancement Surgery 130
Maze Surgery for atrial fibrillation or flutter 356
Mechanical Embolectomy for Treatment of Acute Stroke 184
Mediastinal Germ Cell Tumors 126
Medical Management of Obesity including Anorexiants 379
Medical Policy Alpha Index 505
Medical Policy Group Schedule 501
Medical Policy Matrix By Body Parts 428
Medical Technology Assessment Guidelines 350
Medical Technology Assessment Non-Covered Services 400
Medicare Advantage Prescription Drug Prior Authorization Criteria 108
Medicare Advantage Prescription Drug Quality Care Dosing Guidelines 177
Medicare Advantage Prescription Drug Step Therapy Criteria 109
Medicare HMO Blue and Medicare PPO Blue Non-covered Drug List 023
Medicare Part D Coverage Determination Request Form 442
Meniere's Disease, Hearing Test 425
Meniscal Allograft Transplantation 110
Mesencephalic Transplant, Fetal 361
Methacholine Challenge Test 395
Microprocessor Controlled Prostheses for the Lower Limb 133
Microvolume Straw Technique 086
Minimally Invasive Hip and Total Knee Arthroplasty 199
Minimally Invasive Surgery for Snoring 130
Monitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy 154
Monoclonal Antibody Imaging 378
Morphometric Absorptiometry (MXA) 034
MRI Guided Focused Ultrasound for the Treatment of Uterine Fibroids and Other Tumors 243
MSLT, Multiple Lantency Test 293
Multiple Sleep Latency Test 293
Musculoskeletal Transplant 068
Myelodysplasia/Myelofibrosis 092
N
Neuropsychological Testing 039
NMES (Neuromuscular Electrical Stimulation) 201
Nocturnal Penile Tumescence 078
Non-BRCA Breast Cancer Risk Assessment (OncoVue) 188
Noncontact Radiant Heat Bandage 435
Noncovered Service, Complications 089
O
OBEST, Patient Information 434
Obstructive Sleep Apnea 130
Ocular Photodynamic Therapy 241
Oncologic Applications of PET Scanning 229
Ophthalmologic Techniques to Evaluate the Retinal Nerve Fiber Layer 053
Oral Appliances, Sleep Disorders 293
Orthoptic and/or Pleoptic Training 241
Oscillation Vest, Respiratory Devices 377
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders 120
Osteoarthritis of the Knee 427
Osteochondral Allograft Transplantation 111
Osteochondral Autograft Transplantation 111
Osteoporosis, Bone Densitometry 034
Outpatient Cardiac Rehabilitation 060
Outpatient Electroconvulsive Therapy 319
Outpatient Medical Prior Authorization Form 166
Outpatient Pulmonary Rehabilitation 136
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome 266
Overactive Bladder Medications 170
P
Palatal Stiffening Procedures including Injection of a Sclerosing Agent 130
Pancreas Transplantation Autologous Islet Cell Transplantation 328
Pancreas-Kidney Transplant 328
Parathyroid Hormone (rDNA origin) 018
Partial Left Ventriculectomy 438
Paternal/Fetal Immunotherapy 387
Peak Flow Meters, Respiratory Devices 377
Percutaneous Annuloplasty, Intradiscal Radiofrequency Thermocoagulation, Intradiscal 099
Percutaneous Lumbar Discectomy 231
Percutaneous Myocardial Channeling 424
Percutaneous Transluminal Angioplasty 077
Percutaneous Transmyocardial Laser Revascularization 424Percutaneous Vertebroplasty and Percutaneous Kyphoplasty 105
Perforator Vein Surgery for Chronic Venous Insufficiency 176
Peripheral Stem Cell Support, Autologous 126
Peripheral Vascular Disease Treatment 388
Pharmacogenomic & Metabolite Markers for Patients Treated with Thiopurines 096Phosphodiesterase Type-5 Inhibitors 036
Photocoagulation (feeder vessel technique) 241
Photon Emission Computed Tomography 330
Photorefractive Keratectomy 241
Phototherapeutic Keratectomy 241
Portosystemic Shunt, Transjugular Intrahepatic 370
Positional Magnetic Resonance Imaging 106
Positron Emission Tomography 358
Post-symptom Electrocardiograms 347
Preauthorization Request for Surgical Management of Obesity 047
Preimplantation Genetic Testing 088
Preventive Medicine/Counseling 147
Preventive Screening Tests 413
Prior Auth, Infusion Therapy 430
Prostatic Acid Phosphatase 167
Psychiatric Facility, Transport to 273
R
Radiation Therapy, Intraop 278
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 259
Radiofrequency Ablation of the Pulmonary Vein for Treatment of Atrial Fibrillation 141
Radiofrequency Facet Joint Denervation 140
Radiofrequency Volumetric Tissue Reduction of the Palatal Tissues 130
Radiofrequency Volumetric Tissue Reduction of the Tongue 130
Radiographic Absorptiometry 034
Radioimmunoscintigraphy for Prostate Cancer 378
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma 146
Radiosurgery, Stereotactic 277
Real-Time Intra-Fraction Target Tracking During Radiation Therapy 085
Rehabilitation for Traumatic Brain Injury 436
Repository Emulsion Therapy 217
Respiratory Syncytial Virus Immune Globulin 422
Retroperitoneal Germ Cell Tumors 126
S
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction 153
SAD, Seasonal Affective Disorder 059
Screening for Diabetic Retinopathy 065
Seasonal Affective Disorder 059
Selective Internal Radiation Therapy 278
Semi Implantable Hearing Aid 087
Sensory Integration Therapy 439
Serological Diagnosis of Celiac Disease 138
Serotonin 5-HT 1B,1D Receptor Agonists 169
Signal-Averaged ECG (SAECG) 134
Simultaneous Pancreas-Kidney Transplant 328
Simultaneous Small Bowel/Liver Transplant 368
Single Photon Absorptiometry 034
Sleep Apnea Surgery/Therapy 293
Somatosensory Evoked Potentials 211
Spacers, Respiratory Devices 377
Spinal, Vagal, Deep Brain, Cerebellar Stimulation 083
Stem Cell Transplant, AlloBMT 092
Stem Cell Transplant, AutoBMT 126
Stereotactic Body Radiation Therapy 277
Stimulators, Pelvic Floor Floor 072
Stimulators, Spine 083Surgery for ParkinsonÆs Disease 361
Surgical Management of Obesity 379
Surgical Procedures, Ambulatory 389
Surgical Treatment of Femoroacetabular Impingement 145
Surgical Treatment of Snoring 130
Surgical Vision Services and Vision Training 241
T
Tamiflu® & Relenza® Form for Physicians and Members 441
Technology Assessment Guidelines 350
Tectonic or Optic Keratoplasty 241
Temporomandibular Joint Disorders 035
Testicular Germ Cell Tumors 126
ThAIRapy Vest, Respiratory Devices 377
Thoracic Aortic Aneurysms or Dissections 077
Thorascopic Laser Bullectomy 364
Total Parenteral Nutrition 296
TPN, Total Parenteral Nutrition 296
Traditional Surgical Approaches to Tongue Modification 130
Transanal Endoscopic Microsurgery (TEMS) 200
Transcath Chemoembolization 369
Transcrainial Magnetic Stimulation 319
Transfusion Therapy for Hemolytic Disease 232
Transjugular Intrahepatic Portosystemic Shunt 370
Transmyocardial Laser Revascularization 424
Transplant Simultaneous Small Bowel/Liver 368Transplant, Fetal Mesencephalic 361
Transplant, Multi-visceral 368
Transplant, Musculoskeletal 068
Transplant, Pancreas-Kidney 328
Transport to Psychiatric Facility 273
Transpupillary Thermotherapy for the Treatment of Choroidal Neovascularization 241
Transtelephonic Transmission 347
Treatment of Damaged Myocardium 424
Treatment of Hyperhidrosis 144
Treatment of Telangiectasias 045
Tyrosine Kinase Mutations in Myeloproliferative Neoplasms 079
U
Ultrasound Accelerated Fracture Healing 157
Ultrasound During Pregnancy 007
Ultrasound for Amniocentesis 216
Uvulopalatopharyngoplasty 130V
Vacuum-assisted/Negative Pressure Closure Therapy 435
Vagal Nerve Stimulation for Depression 038
Vaginal Birth After C-Section 147
Ventricular Assist Devices 388Villus Sampling, Chorionic 216
W
Z