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 - Main Page


Ablation Procedures for Peripheral Neuromas 719  

Absorbable Nasal Implant for Treatment of Nasal Valve Collapse 186

Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer 326

Actigraphy 533

Adoptive Immunotherapy including CAR T-Cell therapy 455

Adrenal-to-Brain Transplantation 627

Advanced Imaging of the Heart 972

Advanced Imaging of the Heart CPT and HCPCS Codes 971

Advanced Imaging Radiology 968

AIM Abdomen and Pelvic Imaging CPT and Diagnoses Codes 930

AIM Brain Imaging CPT and Diagnoses Codes 931

AIM Chest Imaging CPT and Diagnoses Codes 932

AIM Extremity Imaging CPT and Diagnoses Codes 933

AIM Head and Neck Imaging CPT and Diagnoses Codes 934

AIM High Technology Radiology Management Program CPT and HCPCS Codes 900

AIM Oncologic Imaging CPT, HCPCS and Diagnoses Codes 929

AIM Specialty Health What's New Page 939

AIM Spine Imaging CPT and Diagnoses Codes 935

AIM Vascular Imaging CPT and Diagnoses Codes 936

Alcohol Injections for Treatment of Peripheral Neuromas 642

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms 155

Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias 190

Allogeneic Pancreas Transplantation 328

Alpha-Fetoprotein-L3 for Detection of Hepatocellular (Liver) Cancer 504

Amniotic Membrane and Amniotic Fluid 643

Ampyra (dalfampridine) 246

Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 557

Analysis of Proteomic Patterns for Early Detection of Cancer 536

Anti-Parkinsonism Drugs 054

Antigen Leukocyte Antibody Test 673

Antihyperlipidemics 013

Antisense Oligonucleotide Medications 027

Applied Behavior Analysis Service Request Form 144

Aqueous Shunts for Glaucoma 223

Artificial Intervertebral Disc: Lumbar Spine 592

Artificial Intervertebral Disc: Cervical Spine 585

Artificial Pancreas Device Systems 720

Assisted Reproductive Services Infertility Services 086

Assisted-Reproductive Technology Services FORM 694

Asthma Management 011

Audio Health Library 506

Auditory Brainstem Implant 481

Auricular Electrostimulation 362

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 111

Autologous Chondrocyte Implantation and Meniscal Allografts 374

Autologous Hematopoietic Stem Cell Transplantation for Malignant Astrocytomas and Gliomas 159

Automated Ambulatory Blood Pressure Monitor 206

Automated Percutaneous Discectomy and Endoscopic Discectomy 231

Automated Point-of Nerve Conduction Tests 222

Autonomic Nervous System Testing 713

Axial Lumbosacral Interbody Fusion (AxiaLIF) 404



B-Type Natriuretic Peptide 031

Balloon Dilation of the Eustachian Tube 018

Balloon Sinuplasty for Treatment of Chronic Sinusitis 582

Baroreflex Stimulation Devices 595

Benign Prostatic Hyperplasia - BPH 040

Benign Skin Lesions 707

Biliopancreatic Bypass 379

Bioengineered Skin and Soft Tissue Substitutes 663

Biofeedback as a Treatment of Chronic Pain 210

Biofeedback as a Treatment of Fecal Incontinence or Constipation 308

Biofeedback as a Treatment of Urinary Incontinence 173

Biofeedback as Psychotherapy 423

Biofeedback for Miscellaneous Indications 187

Biofeedback for the Treatment of Headache 152

Bioimpedance Devices for the Detection of Lymphedema 261

Biomarkers for Diagnosis & Cancer Risk Assessment of Prostate Cancer 336

Birth Control Pills 251

Bisphosphonate, Oral 058

Biventricular Pacemakers - Cardiac Resynchronization Therapy for the Treatment of Heart Failure 101

Blepharoplasty, Blepharoptosis repair, and Brow ptosis repair 740

Blood Pressure Monitors 206

BMI, Body Mass Index 379

Body Mass Index 379

Bone Morphogenetic Protein 097

Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover 549

Botulinum Toxin Injection SP 006

Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds 175

BRAF Kinase and MEK Inhibitors for Unresectable or Metastatic Melanoma 409

Breast Duct Endoscopy 493

Bronchial Thermoplasty 284

Bronchial Valves 313


CA-125 503

Calcitonin Gene-Related Peptide 021

Cancer Therapy, Isolated Limb Perfusion 124

Cardiac Event Monitors 347 

Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 287

Cardiac Rehabilitation in the Outpatient Setting 916

Cardiovascular Risk Panels 664

Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty 219

Catheter Ablation as Treatment for Atrial Fibrillation 141

Caverject 078

CelebrexTM 002

Cell Analysis 341

Cellular Immunotherapy for Prostate Cancer 268

Cerebrospinal Fluid and Urinary Biomarkers of Alzheimer Disease 581

Charged-Particle - Proton or Helium Ion - Radiation Therapy 437

Chelation Therapy 122

Chemical Peels 732

Chimeric Antigen Receptor Therapy for Hematologic Malignancies 066

Chromoendoscopy as an Adjunct to Colonoscopy 904

Circulating Tumor DNA For Cancer 797

Cleft Lip 068

Closure Devices for Patent Foramen Ovale 121

CNS Stimulants and Psychotherapeutic Agents 019

Cochlear Implant 478

Collagen Meniscus Implants 110

Colon Hydrotherapy 178

Complementary Medicine 178

Composite Tissue Allotransplantation of the Hand and Face 662

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications 705

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications 704

Compounded Medications 579

Computed Tomography Perfusion Imaging of the Brain 448

Computer Aided Evaluation as an Adjunct to Magnetic Resonance Imaging of the Breast 578

Computer-Assisted Navigation Orthopedic Procedure 594

Conductive Keratoplasty (CK) 675

Confocal Laser Endomicroscopy 618

Congenital Deformities 068

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 107

Continuous Passive Motion in the Home Setting 407

Cooling Devices Used in the Outpatient Setting 510

Corneal Collagen Cross-linking 905

Corneal Endothelial Microscopy-Specular Microscopy 050

Cosmetic Drugs 251

Cosmetic Services 068

Cox II Inhibitor Drugs 002

Cranial Electrotherapy Stimulaion and Auricular Electrostimulation 362

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 260

Cryosurgical Ablation of Primary or Metastatic Liver Tumors 633

Cryoablation of the Prostate 149

Cytometry 341


Decompression of the Intervertebral Disc Using Laser Energy - or Radiofrequency Coblation - Nucleoplasty 271

Deep Brain Stimulation 473

Dermatologic Applications of Photodynamic Therapy 463

Diabetes Step Therapy 041

Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology 264

Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis 352

Diagnosis and Treatment of Sacroiliac Joint Pain 320

Diaphragmatic Phrenic Nerve and Diaphragm Pacing Systems 593

Dificid fidaxomicin 700

Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant 338

Dopamine Transporter Imaging with Single Photon Emission Computed Tomography 918

Drug Management and Prior Authorization 251

Drug Testing in Pain Management and Substance Use Disorder Treatment 674

Drugs for Cystic Fibrosis 408

Drugs for Weight Loss 572

Dry Needling and Trigger Point Injections for Myofascial Pain 792

Dynamic Posturography 263

Dynamic Spinal Visualization and Vertebral Motion Analysis 195


ECG, Signal-Averaged 134

ECT, Electroconvulsive Therapy 319

Edex 078

E-Blue Review 500

Electrical Bone Growth Stimulation of the Appendicular Skeleton 499

Electrical Stimulation Devices for Psychiatric and Neurological Conditions 157

Electrical Stimulation for the Treatment of Arthritis 302

Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures 498

Electrical Stimulators 003

Electrical Stimulators, PENS 172

Electrocardiogram 347

Electroconvulsive Therapy 319

Electrolysis 068

Electromagnetic Navigation Bronchoscopy 203

Electromyography and Nerve Conduction Studies 701

Electronic Brachytherapy for Nonmelanoma Skin Cancer 739

Electrostimulation and Electromagnetic Therapy for Treating Wounds 655

Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm 009

Elzonris Prior Authorization Request Form 928

Embryonic Mesencephalic Transplantation for the Treatment of Parkinsons Disease 625

End Stage Renal Disease 262

End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema 648

Endobrachial Ultrasound for Diagnosis and Staging of Lung Cancer 715

Endobronchial Brachytherapy 091

Endoscopic Radiofrequency Ablation or Cryoablation for Barretts Esophagus 218

Endoscopic retrograde cholangiopancreatography - ECRP - with Laser or Electrohydraulic Lithotripsy 209

Endothelial Keratoplasty 180

Endovascular Grafts for Abdominal Aortic Aneurysms 098

Endovascular Procedures for Intracranial Arterial Disease - Atherosclerosis and Aneurysms 323

Endovascular Stent Grafts for Disorders of the Thoracic Aorta 233

Endovascular Therapies for Extracranial Vertebral Artery Disease 730

Enhanced External Counterpulsation - EECP - for Chronic Stable Angina or Congestive Heart Failure 649

Enteral Formula 304

Entresto Step Policy 063

Epidural Injections for Neck and Back Pain 690

Epikeratoplasty 675

Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management - Ductal Lavage and Suction Collection Systems 492

Epoetin Alpha 262

Epogen 262

Erectile Dysfunction 078

Erythropoietin 262

Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Treatment Resistant Depression 087

Esophageal pH Monitoring 069

Evoked Potentials 211

Extracorporeal Membrane Oxygenation 726

Extracorporeal Photopheresis 248

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 081

Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome 613


Facet Arthroplasty 174

Facet Joint Denervation 140

FDA-Approved Drugs 251

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 556

Fecal Calprotectin Testing 329

Fecal Microbiota Transplantation 682

Fentanyl, oral-transmucosal 113

Fetal Ultrasound 007

Flow Cytometry 341

Focal Treatments for Prostate Cancer 733

Follitropin Step Therapy 014

Foot Care 385

Foot Care Services 385

Formulae, Enteral 304

Functional Neuromuscular Electrical Stimulation 201


Gamma Interferons 052

Gas Permeable Scleral Contact Lens 371

Gastric Bypass 379

Gastric Electrical Stimulation 636

Gastric Stapling 379

Gastroplasty 379

Gender Affirming Services (Transgender Services) 189

Gene Therapy for Inherited Retinal Dystrophy Luxturna 911

Genetic Testing for Commerical and Medicare Advantage 954

Genetic Testing, Including Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for the Evaluation of Developmental Delay-Intellectual Disability, Autism Spectrum Disorder, and/or Congenital Anomalies 228

Globulin, Respiratory Syncytial Virus Immune 422

Glucagon-like Peptide-1 - GLP-1 - Receptor Agonists 282

Guidelines, Medical Technology Assessment 350

Gynecomastia 068


Hair Prostheses & transplants 068

Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery 546

Heart Assist Devices 280

Heart Transplant 197

Heart/Lung Transplant 269

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia 076

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia 150

Hematopoietic Cell Transplantation for Autoimmune Diseases 192

Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma 074

Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia 212

Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma 205

Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer 204

Hematopoietic Cell Transplantation for Hodgkin Lymphoma 207

Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults 191

Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas 143

Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome 075

Hematopoietic Cell Transplantation for Primary Amyloidosis 181 

Hematopoietic Cell Transplantation for Solid Tumors of Childhood 208

Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors 247

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobutinemia 322

Hepatitis C Medication Management 344

Herbal Therapy 178

HETLIOZ tasimelteon 697

Hexagonal Keratoplasty 675

High-Dose Rate Temporary Prostate Brachytherapy 353

High-Sensitivity C-Reactive Protein 032

Hip Resurfacing 046

Hippotherapy 560

Holistic Medicine 178

Home Cardiorespiratory Monitoring 224

Home Infusion Therapy 430

Home Infusion Therapy, Prior Authorization Guideline 430

Home Total Parenteral Nutrition 296

Home Uterine Activity Monitoring 043

Homeopathy 178

Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease 016

Horizontal Gastric Partitioning 379

Human Anti-hemolytic Factor 360

Hyalgan (Sodium Hyaluronate) 427

Hydrogel Spacer use During Radiotherapy for Prostate Cancer 743

Hyperbaric Oxygen Therapy 653

Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies 048

Hypnotherapy 178


Identification of Microorganisms Using Nucleic Acid Probe 555

Image-Guided Minimally Invasive Decompression for Spinal Stenosis 240

Immune Cell Function Assay in Solid Organ Transplantation 182

Immune Globulin, Respiratory Syncytial Virus 422

Immune Modulating Drugs 004

Immunochemical Fecal Occult Blood Testing 135

Immunomodulators for Skin Conditions 010

Implantable Ambulatory Event Monitors 347

Implantable Bone-Conduction and Bone-Anchored Hearing Aids 479

Implantable Cardioverter Defibrillator 070

Implantable Minature Telescope - IMT 464

Implantation of Intrastromal Corneal Ring Segments 235

In Vivo Analysis of Colorectal Polyps 521

Infergen 052

Infertility Drugs 251

Influenza Drugs 440

Ingestible pH and Pressure Capsule 045

Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates 100

Injectable Asthma Medications 017

Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 471

Injectable Specialty Medication Coverage 071

Injections for Osteoarthritis 427

Interferons Alpha and Gamma 052

Interspinous and Interlaminar Stabilization - Distraction Devices - Spacers 584

Insulin Delivery Devices 332

Insulin Potentiation Therapy 532

Intensity-Modulated Radiation Therapy - IMRT - Abdomen and Pelvis 165

Intensity-Modulated Radiation Therapy - IMRT - Cancer of the Head and Neck or Thyroid 164

Intensity Modulated Radiation Therapy - IMRT - Central Nervous System Tumors 910

Intensity-Modulated Radiation Therapy - IMRT - of the Breast and Lung 163

Intensity Modulated Radiation Therapy - IMRT - of the Prostate 090

Interferential Stimulation for Treatment of Pain 509

Interferons 052

Interleukin-2 (IL-2) 103

Interspinous Distraction Devices or Spacers 584

Interspinous Fixation - Fusion Devices 436

Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain 602

Intracellular Micronutrient Analysis 073

Intraocular Radiation Therapy for Age-Related Macular Degeneration 610

Intraoperative Motor Evoked Potentials 211

Intraoperative Radiation Therapy 278

Intraoperative Somatosensory Evoked Potentials 211

Intraoperative Visual Evoked Potentials 211

Intrastromal ring segments 675

Intravascular Ultrasound 007

Intravenous Anesthetics for the Treatment of Chronic Pain 291

Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 171

Intravenous Immunoglobulin 310

Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions 343

Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions 401

Intravitreal and Punctum Corticosteroid Implants 272 

InVitro Chemoresistance and Chemosensitivity Assays 253

Iontophoresis and Phonophoresis as a Transdermal Technique for Drug Delivery 095

Iridology 178

Islet Transplantation 324

Isolated Limb Perfusion or Infusion for Malignant Melanoma 124

Isolated Small Bowel Transplant 631

IVIg 310


Jaw Disorders (TMJ) 035

Jejunoileal Bypass 379

Jet Injectors, Insulin 332

Jet Pressure Infusion System 332

Joint Fluid Replacement: Synvisc® and Hyalgan® Injections for Osteoarthritis 427


Keratectomy, Photorefractive 675

Keratomileusis 675

Keratophakia 675

Keratoplasty, Lamellar 675

Keratoprosthesis 221

Ketogenic Diet 304

Kidney Transplant 196




Laboratory Testing for HIV Tropism 008

Laboratory Tests for Heart and Kidney Transplant Rejection 530

Lamellar Keratoplasty 675

Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids 244

Laser Bullectomy 364

Laser Treatment of Active Acne 461

Laser Treatment of Onychomycosis 562

Laser-assisted Uvuloplatoplasty (LAUP) 130


Leadless Cardiac Pacemakers 038

Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation 334

Leukocyte Histamine Release Test 589

Limb Perfusion, Isolated 124

Lipectomy 068

Lipid Apheresis 465

Liposuction 068

Liver Transplant and Combined Liver-Kidney Transplant 198

Lobar Lung Transplantation 015

Low-Level Laser Therapy 522

Lung Volume Reduction Surgery for Severe Emphysema 364

Lung Transplantation 015

Lung-Heart Transplant 269

LVRS 364

Lysis of Epidural Adhesions 598


Magnetic Resonance Imaging Targeted Biopsy of the Prostate 747

Magnetoencephalography and Magnetic Source Imaging 137

Mandible, TMJ 035

Manipulation under Anesthesia 483

Massachusetts Standard Form for Medication Prior Authorization Requests 434

Massage therapy 178

Mastopexy 068

Maxillofacial Surgery including Mandibular or Maxillary Advancement Surgery 130

Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders 524

Measurement of Lipoprotein-Associated Phospholipase A2 - Lp-PLA2 - in the Assessment of Cardiovascular Risk 558

Measurement of Serum Antibodies to Infliximab and Adalimumab 917

Medical Benefit Prior Authorization Medication List 034

Med UM and Pharmacy Prior Authorization 033

Medical and Surgical Management of Obesity including Anorexiants 379

Medical Policy Group Schedule 501

Medical Technology Assessment Guidelines 350

Medical Technology Assessment Investigational (Non-Covered) Services List 400 

Medicare Advantage High Technology Radiology & Sleep Disorder Management Redirect 923

Medicare Advantage Part B Step Therapy 020

Medicare Part D Coverage Determination Request Form 442

Medications for Sickle Cell and Beta Thalassemia 083

Melanoma Vaccines 453

Meniscal Allografts and Other Meniscal Implants 110

Methadone Treatment for Opioid Use Disorder 274

Microprocessor Controlled Prostheses for the Lower Limb 133

Microwave Tumor Ablation 912

Mind-Body Medicine 178

Mineral Density Studies 450

Minimally Invasive Coronary Artery Bypass Graft Surgery 553

Minimally Invasive Surgery for Snoring 130

Mini-radial Keratotomy 675

Molecular Panel Testing Cancers 790

Molecular Testing in the Management of Pulmonary Nodules 029

Monitored Anesthesia Care - MAC 154

Monitors, Blood Pressure 206

Morphine 251

MRI-Guided Focused Ultrasound - MRgFUS 243

Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes 654

Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis 677

Multimarker Serum Testing Related to Ovarian Cancer 249

Multispectral Digital Skin Lesion Analysis 748

Multitarget PCR Testing for Diagnosis of Bacterial Vaginosis 711

Mupirocin Step Policy 062

Musculoskeletal Transplant 068

Muse 078

Myelodysplastic Syndromes 155

Myeloproliferative Neoplasms 155

Myocardial Strain Imaging 112

Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure 576

Myoelectric Prosthetic and Components for the Upper Limb 227


Nail Debridement 385

Natrecor 031

Naturopathic Medicine 178

Navigated Transcranial Magnetic Stimulation 596

Negative Pressure Wound Therapy in the Outpatient Setting 543

Nerve Fiber Density Measurement 393

Nerve Graft in Association with Radical Prostatectomy 590

Nesiritide 031

Neural Therapy 914

Neurofeedback 515

Neuropsychological and Psychological Testing 151

New Drug Approval Program 005

Nicotine Products 251

Nocturnal Penile Tumescence 078

Non Covered Drug List 433

Noncontact Ultrasound Treatment for Wounds 657

Noninvasive Fractional Flow Reserve Using Computed Tomography Angiography 028

Non-Invasive Vascular Studies - Duplex Scans 691

Noncontact Radiant Heat Bandage for the Treatment of Wounds 656

Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease 921

Nonpharmacologic Treatment of Rosacea 462

Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 283

Nutrient - Nutritional Panel Testing 745

Nutrition, Home Total Parenteral 296


Obesity Surgery 379

Obstetrical Ultrasound and Ultrasound for Family Planning 007

Obstructive Sleep Apnea 130

Occipital Nerve Stimulation 237

Occlusion of Uterine Arteries Using Transcatheter Embolization 242

Ocular Photodynamic Therapy 599

Omalizumab 017

Oncologic Applications of Photodynamic Therapy, Including Barretts Esophagus 454

Oncology Drugs 409

Open and Thoracoscopic Approaches to Treat Atrial Fibrillation - Maze and Related Procedures 356

Ophthalmic Prostaglandins 346

Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma 053

Opioid Medication Management 102

Optic Keratoplasty 675

Optical Coherence Tomography of the Anterior Eye Segment 084

Optical Coherence Tomography for Imaging of Coronary Arteries 915

Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy 519

Oral Contraceptive 251

Orthotics for Progressive Scoliosis 550

Orthopedic Applications of Platelet-Rich Plasma 737

Orthopedic Applications of Stem Cell Therapy 254

Orthoptic and/or Pleoptic Training 611

Orhtoptic Training for the Treatment of Vision or Learning Disabilities 611

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders 120

Osteoarthritis of the Knee 427

Outpatient Cognitive Rehabilitation 660

Outpatient Electroconvulsive Therapy 319

Outpatient Prior Authorization Code List 072

Outpatient Psychotherapy 423

Outpatient Pulmonary Rehabilitation 136

Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome 266

Overactive Bladder Medications 170

Oxidative Therapy 178


Palatal Stiffening Procedures including Injection of a Sclerosing Agent 130

Panniculectomy 068

Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain 517

Patient-Actuated End Range Motion Stretching Devices 721

Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty 706

Pectus Carinatum 068

Pectus Excavatum 068

Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence 470

Penile Implants 078

Penile Revascularization 078

Pens, Insulin Delivery 332

Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation 485

Percutaneous Electrical Nerve Stimulation - PENS - and Percutaneous Neuromodulation Therapy - PNT 172

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty 482

Percutaneous Lumbar Discectomy 231

Percutaneous Vertebroplasty and Sacroplasty 484

Perfusion, Isolated Limb 124

Peripheral Subcutaneous Field Stimulation 513

Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia 451

Phosphodiesterase Type-5 Inhibitors for Pulmonary Arterial Hypertension 036

Photocoagulation of Macular Drusen 607

Photodynamic Therapy for Choroidal Neovascularization 599

Photorefractive Keratectomy 675

Phototherapeutic Keratectomy 597

Phototherapy PUVA UV-B and Targeted Phototherapy 059

Phrenic Nerve Stimulation for Central Sleep Apnea 955

PKU 304

Placental or Umbilical Cord Blood as a Source of Stem Cells 285

Plasma Exchange 466

Plastic Surgery 068

Plugs for Fistula Repair 528

Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers 354 

Polarity Therapy 178

Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction 583

Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis 541

Post-symptom Electrocardiograms 347

Posturography, Dynamic 263

Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities 718

Preauthorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain for MP 320 - 927

Preauthorization Request Form for 379 Surgical Management of Obesity Policy 047

Preauthorization Request Form for Gene Therapy for Inherited Retinal Dystrophy 926

Prior Authorization Request Form for Artificial Intervertebral Disc Cervical Spine MP 585, 952

Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel) MP 455, 925

Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma 924

Prior Authorization Request  Form for Gender Affirming Services (Transgender Services) MP 189, 901

Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189, 902

Prior Authorization Request Form for Esketamine Nasal Spray and Intravenous Ketamine for Treatment Resistant Depression 094

Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb MP 227, 938

Prior Authorization Request Form for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease MP 920, 956

Prior Authorization Request Form for Therapeutic Radiopharmaceuticals in Oncology Lutetium 177 958

Prior Authorization Request Form for Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy MP 008 085

Prior Authorization Request  Form for Zulresso (Brexanalone) for the Treatment of Postpartum Depression 148

Pregabalin (Lyrica and Lyrica CR) 057

Pregnancy, Ultrasound 007

Preimplantation Genetic Testing 088

Preventive Screening Tests 413

Prior Auth, Infusion Therapy 430

Prior Authorization Medication Instruction Form 023

Procrit 262

Procuren 251

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia 652

Prolotherapy 183

Prostaglandin 078

Prostate Ultrasound 007

Prostatic Urethral Lift 744

Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer 709

Proton Pump Inhibitors 030

Psychoanalysis 423

Psychotherapy, Outpatient 423

Pumps, Insulin 332


Qi Gong 178

Quality Care Dosing Guidelines 621A

Quality Care Dosing Guidelines Drug List 621B

Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers 397

Quantitative Electroencephalography as a Diagnostic Aid for Attenion-Deficit Hyperactivity Disorder 554 

Quantitative Sensory Testing 258


Radial Keratotomy 675

Radiation Therapy, Intraop 278 

Radioactive Seed Localization of Nonpalpable Breast Lesions 469

Radioembolization for Primary and Metastatic Tumors of the Liver 292

Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 259

Radiofrequency Ablation of Peripheral Nerves to Treat Pain 794

Radiofrequency Ablation of Primary or Metastatic Liver Tumors 286

Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension 919

Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions 080

Radiofrequency Volumetric Tissue Reduction of the Palatal Tissues 130

Radiofrequency Volumetric Tissue Reduction of the Tongue 130

Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using In-111 Satumomab Pendetide - OncoScint - or Tc-99m Arcitumomab - IMMU-4, CEA-Scan 638

Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using Technetium-99m Nofetumomab Merpentan - Verluma 640

Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging with Indium-111 Capromab Pendetide for Prostate Cancer 639

Recombinant Human 262

Reconstructive Breast Surgery-Management of Breast Implants 428

Reconstructive Surgery 068

Reduction Mammaplasty for Breast-Related Symptoms 703

Reflexology 178

Reiki 178

Request for Clinical Exception to BCBSMA Charged Particle - Proton Beam - Policy and Notification 678

Request for Clinical Exception to BCBSMA Intensity Modulated Radiation Therapy (IMRT) Policy and Notification 325

Request for Clinical Exception to BCBSMA Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy - SBRT - Policy 922

Repository Corticotropin Injection (H.P Acthar Gel) 064

RespiGamTM 422

Respiratory Syncytial Virus Immune Globulin 422

Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy 716

Restasis - Topical Ocular Hydrating Agents 426

Retail Pharmacy Prior Authorization Policy 049

Retin A 251

Retinal Imaging 065

Retinal Prosthesis 606

Retinal Telescreening for Diabetic Retinopathy 065

Revascularization, Penile 078

Rhinomanometry and Acoustic or Optical Rhinometry 586

Rhinophyma 068

Rhinoplasty 068

Rhytidectomy 068

Ritalin 251

Rolfing 178

Routine Foot Care and Debridement of Toenails 385




Sacral Nerve Neuromodulation/Stimulation 153


Saturation Biopsy for Diagnosis and Staging of Prostate Cancer 307

Scenesse afamelanotide for the treatment of Erythropoietic protoporphyria 077

Scintimammography, Breast-Specific Gamma Imaging, and Molecular Breast Imaging 494

Scleral Lens 371

Selective Internal Radiation Therapy 278

Semi-Implantable and Fully Implantable Middle Ear Hearing Aid 480

Sensory Integration Therapy 659

SEP 211

Serological Diagnosis of Celiac Disease 138

Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease 551

Serum Biomarker Human Epididymis Protein 4 - HE4 290

Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases 702

Serum Tumor Markers for Breast and Gastrointestinal Malignancies 538

Sex Reassignment Surgery 068

Sexual Dysfunction 078

Shoulder Resurfacing 156

Signal-Averaged Electrocardiography - SAECG 134

Sleep Disorder Management 969

Sleep Disorder Management CPT and HCPCS Codes 970

Small Bowel, Liver, and Multivisceral Transplant 632

Soliris and Ultomiris 093

Somatosensory Evoked Potentials 211

Special Formulae 304

Specialty Pharmacy List 051

Sphenopalatine Ganglion Block for Headache 026

Spinal Cord and Dorsal Root Ganglion Stimulation 472

Spinal Muscular Atrophy (SMA) Medications 044

Stapling, Gastric 379

Stem-cell Therapy for Peripheral Arterial Disease 348

Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinsons Disease 626

Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 277

Steroid-Eleuting Sinus Stents 800

Stimulators 003

Stimulators, PENS 172

Sublingual Immunotherapy with Allergen-specific Extracts - SLIT 681

Subtalar Arthroereisis 299

Suprachoroidal Delivery of Pharmacologic Agents 609

Surgery for Groin Pain in Athletes 695

Surgical and Debulking Treatments for Lymphedema 037

Surgical Deactivation of Headache Trigger Sites 801

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea 570

Surgical Management of Obesity 379

Surgical Treatment of Femoroacetabular Impingement 145

Surgical and Non-Surgical Treatment of Gynecomastia 661

Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease 920

Surgical Treatment of Snoring 130

Surgical Ventricular Restoration 544

Syncytial Virus Immune Globulin, Respiratory 422

Synvisc® 427

Systems Pathology in Prostate Cancer 250


Tattoos 068

Technology Assessment Guidelines 350

Tectonic or Optic Keratoplasty 675

Temporomandibular Joint Disorder 035

Testing Serum Vitamin D Levels 746

Therapeutic Radiopharmaceuticals in Oncology 028

Thermal Capsulorrhaphy as a Treatment of Joint Instability 591

Thermography 342

Threshold Electrical Stimulation as a Treatment of Motor Disorders 321

TIF procedure for Gastroesophageal Reflux Disease 920

Tilt Table Testing 359

Toenails, Debridement of 385

Topical Testosterone 345

Total Ankle Replacement 193

Total Artificial Hearts and Implantable Ventricular Assist Devices 280

Total Parenteral Nutrition 296

TPN, Total Parenteral Nutrition 296

Traditional Surgical Approaches to Tongue Modification 130

Transanal Endoscopic Microsurgery 200

Transanal Radiofrequency Treatment of Fecal Incontinence 309

Transcatheter Aortic-Valve Implantation for Aortic Stenosis 392

Transcatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic Liver Malignancies 634

Transcatheter Mitral Valve Repair 692

Transcatheter Pulmonary Valve Implantation 403

Transcranial Doppler US 007

Transcranial Magnetic Stimulation 319

Transcranial Magnetic Stimulation as a Treatment of Depression 297

Transcutaneous Electrical Nerve Stimulation 003

Transmyocardial Revascularization 651

Transplant, Allogeneic Pancreas 328

Transplant, Heart 197

Transplant, Heart-Lung 269

Transplant, Kidney/ Renal 196

Transplant, Liver 198

Transplant, Lobar Lung 015

Transplant, Lung 015

Transplant, Musculoskeletal 068

Transpupillary Thermotherapy for the Treatment of Choroidal Neovascularization 600

Transrectal Ultrasound 007

Transrectal Ultrasound for Staging Rectal Cancer 679

Transrectal Ultrasound of the Protate 680

Transtelephonic Transmission 347

Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia 060

Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence 523

Transvaginal Ultrasound 007

Treatment of Hyperhidrosis 406

Treatment of Tinnitus 267

Treatment of Varicose Veins and Venous Insufficiency 238

Trigger Point and Tender Point Injections 604

Tumescence Test 078

Tumor Markers for Diagnosis and Management of Cancer 167


Ultrafiltration in Decompensated Heart Failure 542

Ultrasonographic Evaluation of Skin Lesions 303

Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis 547

Ultrasound 007

Ultrasound Accelerated Fracture Healing Device 497

Ultrasound During Pregnancy 007

Ultrasound for the Evaluation of Paranasal Sinuses 445

Ultrasound, Cranial 007

Ultrasound, Duplex 007

Ultrasound, Fetal, 007

Ultrasound, Intravascular 007

Ultrasound, Obstetrical 007

Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral 742

Uterine Monitoring 043

Uvulopalatopharyngoplasty 130


Vagus Nerve Blocking Therapy for Treatment of Obesity 644

Vagus Nerve Stimulation 474

Ventricular Assist Devices 280

Vertebral Axial Decompression 603 

Vertebral Fracture Assessment with Densitometry 449

Vertical Expandable Prosthetic Titanium Rib 305

Vestibular Dysfunction 263

Vestibular Function Testing 024

Viagra 078

VioxxTM 002

Viscocanalostomy and Canaloplasty 372

Vision Services 675 

Visual Evoked Potentials 211


Wearable Cardioverter Defibrillators 042

Weight Loss Drugs 379

Whole-Body Computed Tomography Scan as a Screening Test 447

Whole Body Dual X-Ray Absorptiometry to Determine Body Composition 577

Wigs 068

Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon 185

Wireless Pressure Sensors in Endovascular Aneurysm Repair 306


Xolair 017


Yohimbine 078


Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy 008

ZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression 147