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621 A Quality Care Dosing Guidelines
719 Ablation Procedures for Peripheral Neuromas
186 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
111 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
533 Actigraphy
841 Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia
455 Adoptive Immunotherapy
946 Aducanumab for Alzheimer Disease
972 Advanced Imaging of the Heart
971 Advanced Imaging of the Heart CPT and HCPCS Codes
968 Advanced Imaging Radiology
930 AIM Abdomen and Pelvic Imaging CPT and Diagnoses Codes
931 AIM Brain Imaging CPT and Diagnoses Codes
932 AIM Chest Imaging CPT and Diagnoses Codes
933 AIM Extremity Imaging CPT and Diagnoses Codes
954 AIM Genetic Testing Management Program
957 AIM Genetic Testing Management Program CPT and HCPCS Codes
934 AIM Head and Neck Imaging CPT and Diagnoses Codes
900 AIM High Technology Radiology Management Program CPT and HCPCS Codes
929 AIM Oncologic Imaging CPT, HCPCS and Diagnoses Codes
099 AIM Oncology Medication Management Program
939 AIM Specialty Health What's New Page
935 AIM Spine Imaging CPT and Diagnoses Codes
936 AIM Vascular Imaging CPT and Diagnoses Codes
142 Air Ambulance Transport
190 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
155 Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
328 Allogeneic Pancreas Transplant
838 Allograft Injection for Degenerative Disc Disease
347 Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry
643 Amniotic Membrane and Amniotic Fluid
246 Ampyra dalfampridine
557 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
536 Analysis of Proteomic Patterns for Early Detection of Cancer
021 Anti-Migraine Policy
054 Anti-Parkinsonism Drugs
673 Antigen Leukocyte Antibody Test
013 Antihyperlipidemics
027 Antisense Oligonucleotide Medications
144 Applied Behavior Analysis Service Request Form
091 Applied Behavioral Analysis (ABA)
223 Aqueous Shunts and Stents for Glaucoma
585 Artificial Intervertebral Disc - Cervical Spine
592 Artificial Intervertebral Disc - Lumbar Spine
086 Assisted Reproductive Services Infertility Services
694 Assisted Reproductive Technology Services Form for Policy Infertility Diagnosis and Treatment
011 Asthma and Chronic Obstructive Pulmonary Disease Medication Management
506 AudioHealth Library
481 Auditory Brainstem Implant
374 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
206 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
231 Automated Percutaneous and Percutaneous Discectomy
713 Autonomic Nervous System Testing
404 Axial Lumbosacral Interbody Fusion
621 B Quality Care Dosing Guidelines Drug List
018 Balloon Dilation of the Eustachian Tube
582 Balloon Sinuplasty for Treatment of Chronic Sinusitis
595 Baroreflex Stimulation Devices
040 Benign Prostatic Hyperplasia - BPH
707 Benign Skin Lesions
663 Bioengineered Skin and Soft Tissue Substitutes
210 Biofeedback as a Treatment of Chronic Pain
308 Biofeedback as a Treatment of Fecal Incontinence or Constipation
173 Biofeedback as a Treatment of Urinary Incontinence
187 Biofeedback for Miscellaneous Indications
152 Biofeedback for the Treatment of Headache
261 Bioimpedance Devices for the Detection of Lymphedema
336 Biomarkers for Diagnosis & Cancer Risk Assessment of Prostate Cancer
058 Bisphosphonates, Oral
101 Biventricular Pacemakers - Cardiac Resynchronization Therapy for the Treatment of Heart Failure
740 Blepharoplasty Blepharoptosis repair and Brow ptosis repair
097 Bone Morphogenetic Protein
549 Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
006 Botulinum Toxin Injections SP
493 Breast Duct Endoscopy
284 Bronchial Thermoplasty
313 Bronchial Valves
503 CA-125
287 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
916 Cardiac Rehabilitation in the Outpatient Setting
664 Cardiovascular Risk Panels
219 Carotid Stent Placemen
141 Catheter Ablation as Treatment for Atrial Fibrillation
122 Chelation Therapy
732 Chemical Peels
066 Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
942 Chimeric Antigen Receptor Therapy for Multiple Myeloma ABECMA (Idecabtagene Vicleucel)
904 Chromoendoscopy as an Adjunct to Colonoscopy
121 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
019 CNS Stimulants and Psychotherapeutic Agents
478 Cochlear Implant
178 Complementary Medicine
662 Composite Tissue Allotransplantation of the Hand and Face
705 Compound Medications Exclusion Drug List
579 Compounded Medications
594 Computer-Assisted Navigation Orthopedic Procedure
618 Confocal Laser Endomicroscopy
107 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems
407 Continuous Passive Motion in the Home Setting
510 Cooling Devices Used in the Outpatient Setting
905 Corneal Collagen Cross-linking
002 Cox II Inhibitor Drugs
362 Cranial Electrotherapy Stimulation and Auricular Electrostimulation
260 Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
843 Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis
633 Cryosurgical Ablation of Primary or Metastatic Liver Tumors
271 Decompression of the Intervertebral Disc Using Laser Energy - or Radiofrequency Coblation - Nucleoplasty
473 Deep Brain Stimulation
463 Dermatologic Applications of Photodynamic Therapy
041 Diabetes Step Therapy
264 Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology
352 Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
320 Diagnosis and Treatment of Sacroiliac Joint Pain
139 Diagnostic Laboratory Services
593 Diaphragmatic Phrenic Nerve and Diaphragm Pacing Systems
175 Digital Health Technologies Diagnostic Applications
947 Digital Health Therapies for Attention Deficit
411 Directory of Documents
338 Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant
918 Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
049 Drug Management & Retail Pharmacy Prior Authorization Policy
251 Drug Management and Prior Authorization
674 Drug Testing in Pain Management and Substance Use Disorder Treatment
408 Drugs for Cystic Fibrosis
572 Drugs for Weight Loss
164 Dry Hydrotherapy for chronic pain conditions
792 Dry Needling and Trigger Point Injections for Myofascial Pain
842 Durable Medical Equipment DME
263 Dynamic Posturography
195 Dynamic Spinal Visualization and Vertebral Motion Analysis
023 E Form medication prior auth instruction
499 Electrical Bone Growth Stimulation of the Appendicular Skeleton
157 Electrical Stimulation Devices for Psychiatric and Neurological Conditions
302 Electrical Stimulation for the Treatment of Arthritis
498 Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
203 Electromagnetic Navigation Bronchoscopy
701 Electromyography and Nerve Conduction Studies
655 Electrostimulation and Electromagnetic Therapy for Treating Wounds
009 Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm
928 Elzonris Prior Authorization Request Form MP 009
648 End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema
715 Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
218 Endoscopic Radiofrequency Ablation or Cryoablation for Barretts Esophagus
180 Endothelial Keratoplasty
098 Endovascular Grafts for Abdominal Aortic Aneurysms
323 Endovascular Procedures for Intracranial Arterial Disease - Atherosclerosis and Aneurysms
233 Endovascular Stent Grafts for Disorders of the Thoracic Aorta
730 Endovascular Therapies for Extracranial Vertebral Artery Disease
649 Enhanced External Counterpulsation - EECP - for Chronic Stable Angina or Congestive Heart Failure
162 Entyvio ( Vedolizumab ) Policy
690 Epidural Steroid Injections for Neck and Back Pain
492 Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management - Ductal Lavage and Suction Collection Systems
262 Erythropoietin Recombinant Human
087 Esketamine Nasal Spray (SpravatoTM) and Intravenous Ketamine for Mental Health Conditions
069 Esophageal pH Monitoring
581 Evaluation of Biomarkers for Alzheimer Disease
726 Extracorporeal Membrane Oxygenation
248 Extracorporeal Photopheresis
081 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
613 Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
174 Facet Arthroplasty
140 Facet Joint Denervation
556 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
329 Fecal Calprotectin Testing
682 Fecal Microbiota Transplantation
113 Fentanyl, oral-transmucosal
341 Flow Cytometry for Cell Analysis
733 Focal Treatments for Prostate Cancer
201 Functional Neuromuscular Electrical Stimulation
371 Gas Permeable Scleral Contact Lens pdf.pdf
636 Gastric Electrical Stimulation
189 Gender Affirming Services (Transgender Services)
215 Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel
911 Gene Therapy for Inherited Retinal Dystrophy Luxturna
146 Ground Ambulance
257 Growth Hormone and Insulin-like Growth Factor
546 Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery
063 Heart Failure and Hypertrophic Cardiomyopathy (HCM) Policy
269 Heart Lung Transplant
197 Heart Transplant
076 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
150 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
192 Hematopoietic Cell Transplantation for Autoimmune Diseases
074 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
212 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
205 Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
204 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
207 Hematopoietic Cell Transplantation for Hodgkin Lymphoma
191 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
143 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
075 Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome
181 Hematopoietic Cell Transplantation for Primary Amyloidosis
208 Hematopoietic Cell Transplantation for Solid Tumors of Childhood
247 Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors
322 Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
697 HETLIOZ tasimelteon
032 High-Sensitivity C-Reactive Protein
046 Hip Resurfacing
560 Hippotherapy
224 Home Cardiorespiratory Monitoring
430 Home Infusion Therapy Prior Authorization Form
296 Home Total Parenteral Nutrition TPN
016 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
360 Human Anti hemophilic Factor
653 Hyperbaric Oxygen Therapy
048 Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
131 Hypoactive Sexual Desire Disorder (HSDD) Policy
555 Identification of Microorganisms Using Nucleic Acid Probe
240 Image-Guided Minimally Invasive Decompression for Spinal Stenosis
182 Immune Cell Function Assay in Solid Organ Transplantation
004 Immune Modulating Drugs
310 Immunoglobulins Policy
010 Immunomodulators for Skin Conditions
479 Implantable Bone-Conduction and Bone-Anchored Hearing Aids
070 Implantable Cardioverter Defibrillator
521 In Vivo Analysis of Colorectal Polyps
440 Influenza Drugs Tamiflu and Relenza
100 Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates
017 Injectable Asthma Medications
471 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
071 Injectable Specialty Medication Coverage
427 Injections for Osteroarthritis
332 Insulin Delivery Devices
532 Insulin Potentiation Therapy
509 Interferential Stimulation for Treatment of Pain
052 Interferons Alpha and Gamma
584 Interspinous and Interlaminar Stabilization-Distraction Devices - Spacers
436 Interspinous Fixation - Fusion Devices
073 Intracellular Micronutrient Analysis
610 Intraocular Radiation Therapy for Age-Related Macular Degeneration
211 Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
291 Intravenous Anesthetics for the Treatment of Chronic Pain
171 Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
272 Intravitreal and Punctum Corticosteroid Implants
095 Iontophoresis and Phonophoresis as a Transdermal Technique for Drug Delivery
324 Islet Transplantation
631 Isolated Small Bowel Transplant
0
196 Kidney Transplant
244 Laparoscopic andTranscervical Techniques for the Myolysis of Uterine Fibroids
948 Laser Interstitial Thermal Therapy for Neurological Conditions
461 Laser Treatment of Active Acne
562 Laser Treatment of Onychomycosis
038 Leadless Cardiac Pacemakers
334 Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
589 Leukocyte Histamine Release Test
465 Lipid Apheresis
198 Liver Transplant and Combined Liver-Kidney Transplant
522 Low-Level Laser Therapy
015 Lung and Lobar Lung Transplant
364 Lung Volume Reduction Surgery for Severe Emphysema
483 Manipulation under Anesthesia
365 Manual and Power Operated Wheelchairs
434 Massachusetts Standard Form for Medication Prior Authorization Requests
163 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
524 Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
558 Measurement of Lipoprotein-Associated Phospholipase A2 - Lp-PLA2 - in the Assessment of Cardiovascular Risk
917 Measurement of Serum Antibodies to Selected Biologic Agents
033 Med UM Policy
379 Medical and Surgical Management of Obesity including Anorexiants
034 Medical Benefit Prior Authorization Medication List
999 Medical Policy Updates
350 Medical Technology Assessment Guidelines
400 Medical Technology Assessment NonCovered Services
923 Medicare Advantage High Technology Radiology & Sleep Disorder Management Redirect
132 Medicare Advantage Management
020 Medicare Advantage Part B Step Therapy
125 Medicare Advantage Part B Utilization Management
442 Medicare Part D Coverage Determination Request Form
083 Medications for Sickle Cell and Beta Thalassemia
453 Melanoma Vaccines
110 Meniscal Allografts and Other Meniscal Implants
274 Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction
840 Methotrexate Step Therapy
133 Microprocessor Controlled Prostheses for the Lower Limb
912 Microwave Tumor Ablation
450 Mineral Density Studies
744 Minimally Invasive and surgical treatment options for Benign Prostatic Hyperplasia
029 Molecular Testing in the Management of Pulmonary Nodules
154 Monitored Anesthesia Care - MAC
243 MRI-Guided Focused Ultrasound - MRgFUS
677 Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis
249 Multimarker Serum Testing Related to Ovarian Cancer
839 Multiple Sclerosis Step Therapy
748 Multispectral Digital Skin Lesion Analysis
711 Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
062 Mupirocin Step Policy
112 Myocardial Strain Imaging
576 Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure
227 Myoelectric Prosthetic and Components for the Upper Limb
596 Navigated Transcranial Magnetic Stimulation
543 Negative Pressure Wound Therapy in the Outpatient Setting
393 Nerve Fiber Density Measurement
590 Nerve Graft in Association with Radical Prostatectomy
914 Neural Therapy
515 Neurofeedback
151 Neuropsychological and Psychological Testing
005 New Drug Approval Program
462 Non pharmacologic Treatment of Rosacea
691 Non-Invasive Vascular Studies - Duplex Scans
657 Noncontact Ultrasound Treatment for Wounds
433 Noncovered Drug List
921 Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
123 Nononcologic Uses of Rituximab
283 Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
745 Nutrient - Nutritional Panel Testing
0
517 Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain
045 Pathogen Panel Testing
721 Patient-Actuated End Range Motion Stretching Devices
706 Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty
470 Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence
485 Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation
922 Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders
172 Percutaneous Electrical Nerve Stimulation - PENS - and Percutaneous Neuromodulation Therapy - PNT
482 Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation
583 Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction
484 Percutaneous Vertebroplasty and Sacroplasty
513 Peripheral Subcutaneous Field Stimulation
451 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
344 Pharmacy Hepatitis C Medication Management
051 Pharmacy Specialty List
036 Phosphodiesterase Type-5 Inhibitors for Pulmonary Arterial Hypertension
607 Photocoagulation of Macular Drusen
599 Photodynamic Therapy for Choroidal Neovascularization
059 Phototherapy PUVA UV-B and Targeted Phototherapy
955 Phrenic Nerve Stimulation for Central Sleep Apnea
466 Plasma Exchange
068 Plastic Surgery
528 Plugs for Fistula Repair
354 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
541 Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
718 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
047 Preauthorization Request Form for 379 Surgical Management of Obesity Policy
927 Preauthorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain for MP 320
926 Preauthorization Request Form for Gene Therapy for Inherited Retinal Dystrophy
057 Pregabalin (Lyrica and Lyrica CR)
088 Preimplantation Genetic Testing
413 Preventive Screening Tests
952 Prior Authorization Request Form for Artificial Intervertebral Disc Cervical Spine MP 585
942 Prior Authorization Request Form for CAR T-Cell Therapy Services for Multiple Myeloma ABECMA (Idecabtagene Vicleucel)
945 Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (Brexucabtagene Autoleucel)
925 Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel) MP 066
944 Prior Authorization Request Form for CAR T-Cell Therapy Services for Follicular Lymphoma (Axicabtagene Ciloleucel)
940 Prior Authorization Request Form for CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) MP 066
941 Prior Authorization Request Form for CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel)
924 Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma
845 Prior Authorization Request Form for Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems
902 Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189
094 Prior Authorization Request Form for Esketamine Nasal Spray and Intravenous Ketamine for Mental Health Conditions
901 Prior Authorization Request Form for Gender Affirming Services (Transgender Services) MP 189
216 Prior Authorization Request Form for Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel
973 Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb MP 227
160 Prior Authorization Request Form for Scenesse MP 077
956 Prior Authorization Request Form for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease MP 920
085 Prior Authorization Request Form for Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy MP 008
148 Prior Authorization Request Form for Zulresso (Brexanalone) for the Treatment of Postpartum Depression
652 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
183 Prolotherapy
709 Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer
030 Proton Pump Inhibitors
937 Quality Care Cancer Program (Radiation Oncology)
938 Quality Care Cancer Program (Radiation Oncology) CPT and HCPCS Codes
554 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit Hyperactivity Disorder
258 Quantitative Sensory Testing
292 Radioembolization for Primary and Metastatic Tumors of the Liver
259 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
794 Radiofrequency Ablation of Peripheral Nerves to Treat Pain
286 Radiofrequency Ablation of Primary or Metastatic Liver Tumors
919 Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
080 Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
428 Reconstructive Breast Surgery-Management of Breast Implants
703 Reduction Mammaplasty for Breast-Related Symptoms
145 Remote Electrical Neuromodulation for Migraines
064 Repository Corticotropin Injection (H.P Acthar Gel).pdf
716 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
606 Retinal Prosthesis
065 Retinal Telescreening for Diabetic Retinopathy
586 Rhinomanometry and Acoustic or Optical Rhinometry
385 Routine Foot Care and Debridement of Toenails
422 RSV Immunoprophylaxis
153 Sacral Nerve Neuromodulation-Stimulation
307 Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
077 Scenesse afamelanotide for the treatment of Erythropoietic protoporphyria
494 Scintimammography, Breast-Specific Gamma Imaging, and Molecular Breast Imaging
480 Semi-Implantable and Fully Implantable Middle Ear Hearing Aid
659 Sensory Integration Therapy
138 Serological Diagnosis of Celiac Disease
551 Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
290 Serum Biomarker Human Epididymis Protein 4 - HE4
702 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
538 Serum Tumor Markers for Breast and Gastrointestinal Malignancies
078 Sexual Dysfunction Diagnosis and Therapy
156 Shoulder Resurfacing
134 Signal-Averaged Electrocardiography - SAECG
969 Sleep Disorder Management
970 Sleep Disorder Management CPT and HCPCS Codes
632 Small Bowel, Liver, and Multivisceral Transplant
093 Soliris, Ultomiris, Myasthenia Gravis, and Neuromyelitis Optica
304 Special Foods
026 Sphenopalatine Ganglion Block for Headache
472 Spinal Cord and Dorsal Root Ganglion Stimulation
044 Spinal Muscular Atrophy (SMA) Medications
530 ST2 Assay for Chronic Heart Failure
348 Stem-cell Therapy for Peripheral Arterial Disease
800 Steroid-Eluting Sinus Stents
681 Sublingual Immunotherapy with Allergen-specific Extracts - SLIT
299 Subtalar Arthroereisis
105 Supportive Care Treatments for Patients with Cancer
609 Suprachoroidal Delivery of Pharmacologic Agents
695 Surgery for Groin Pain in Athletes
037 Surgical and Debulking Treatments for Lymphedema
661 Surgical and Non-surgical Treatment of Gynecomastia
920 Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease
801 Surgical Deactivation of Headache Trigger Sites
570 Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
176 Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation
130 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
544 Surgical Ventricular Restoration
250 Systems Pathology in Prostate Cancer
035 Temporomandibular Joint Disorder
342 Thermography
321 Threshold Electrical Stimulation as a Treatment of Motor Disorders
345 Topical Testosterone
426 Topical_Ocular_Hydrating_Agents
193 Total Ankle Replacement
280 Total Artificial Hearts and Implantable Ventricular Assist Devices
200 Transanal Endoscopic Microsurgery
392 Transcatheter Aortic-Valve Implantation for Aortic Stenosis
634 Transcatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic Liver Malignancies
692 Transcatheter Mitral Valve Repair
403 Transcatheter Pulmonary Valve Implantation
297 Transcranial Magnetic Stimulation as a Treatment of Depression
003 Transcutaneous Electrical Nerve Stimulation
651 Transmyocardial Revascularization
600 Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization
523 Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
406 Treatment of Hyperhidrosis
267 Treatment of Tinnitus
238 Treatment of Varicose Veins and Venous Insufficiency
604 Trigger Point and Tender Point Injections
167 Tumor Markers for diagnosis and management of cancer
303 Ultrasonographic Evaluation of Skin Lesions
547 Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
497 Ultrasound Accelerated Fracture Healing Device
445 Ultrasound for the Evaluation of Paranasal Sinuses
742 Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral
370 Urological Supplies
060 Uterus Transplantation for Absolute Uterine Factor Infertility
474 Vagus Nerve Stimulation
092 Vascular Endothelial Growth Factor (VEGF) Inhibitors Step Therapy
603 Vertebral Axial Decompression
449 Vertebral Fracture Assessment with Densitometry
305 Vertical Expandable Prosthetic Titanium Rib
024 Vestibular Function Testing
372 Viscocanalostomy and Canaloplasty
675 Vision Services
746 Vitamin D Assay Testing
042 Wearable Cardioverter Defibrillators
577 Whole Body Dual X-Ray Absorptiometry to Determine Body Composition
149 Whole Gland Cryoablation of the Prostate
447 Whole-Body Computed Tomography Scan as a Screening Test
185 Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
306 Wireless Pressure Sensors in Endovascular Aneurysm Repair
0
0
008 Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy
147 ZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression
621 A Quality Care Dosing Guidelines
719 Ablation Procedures for Peripheral Neuromas
186 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
111 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
533 Actigraphy
841 Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia
455 Adoptive Immunotherapy
946 Aducanumab for Alzheimer Disease
972 Advanced Imaging of the Heart
971 Advanced Imaging of the Heart CPT and HCPCS Codes
968 Advanced Imaging Radiology
930 AIM Abdomen and Pelvic Imaging CPT and Diagnoses Codes
931 AIM Brain Imaging CPT and Diagnoses Codes
932 AIM Chest Imaging CPT and Diagnoses Codes
933 AIM Extremity Imaging CPT and Diagnoses Codes
954 AIM Genetic Testing Management Program
957 AIM Genetic Testing Management Program CPT and HCPCS Codes
934 AIM Head and Neck Imaging CPT and Diagnoses Codes
900 AIM High Technology Radiology Management Program CPT and HCPCS Codes
929 AIM Oncologic Imaging CPT, HCPCS and Diagnoses Codes
099 AIM Oncology Medication Management Program
939 AIM Specialty Health What's New Page
935 AIM Spine Imaging CPT and Diagnoses Codes
936 AIM Vascular Imaging CPT and Diagnoses Codes
142 Air Ambulance Transport
190 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
155 Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
328 Allogeneic Pancreas Transplant
838 Allograft Injection for Degenerative Disc Disease
347 Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry
643 Amniotic Membrane and Amniotic Fluid
246 Ampyra dalfampridine
557 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
536 Analysis of Proteomic Patterns for Early Detection of Cancer
021 Anti-Migraine Policy
054 Anti-Parkinsonism Drugs
673 Antigen Leukocyte Antibody Test
013 Antihyperlipidemics
027 Antisense Oligonucleotide Medications
144 Applied Behavior Analysis Service Request Form
091 Applied Behavioral Analysis (ABA)
223 Aqueous Shunts and Stents for Glaucoma
585 Artificial Intervertebral Disc - Cervical Spine
592 Artificial Intervertebral Disc - Lumbar Spine
086 Assisted Reproductive Services Infertility Services
694 Assisted Reproductive Technology Services Form for Policy Infertility Diagnosis and Treatment
011 Asthma and Chronic Obstructive Pulmonary Disease Medication Management
506 AudioHealth Library
481 Auditory Brainstem Implant
374 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
206 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
231 Automated Percutaneous and Percutaneous Discectomy
713 Autonomic Nervous System Testing
404 Axial Lumbosacral Interbody Fusion
621 B Quality Care Dosing Guidelines Drug List
018 Balloon Dilation of the Eustachian Tube
582 Balloon Sinuplasty for Treatment of Chronic Sinusitis
595 Baroreflex Stimulation Devices
040 Benign Prostatic Hyperplasia - BPH
707 Benign Skin Lesions
663 Bioengineered Skin and Soft Tissue Substitutes
210 Biofeedback as a Treatment of Chronic Pain
308 Biofeedback as a Treatment of Fecal Incontinence or Constipation
173 Biofeedback as a Treatment of Urinary Incontinence
187 Biofeedback for Miscellaneous Indications
152 Biofeedback for the Treatment of Headache
261 Bioimpedance Devices for the Detection of Lymphedema
336 Biomarkers for Diagnosis & Cancer Risk Assessment of Prostate Cancer
058 Bisphosphonates, Oral
101 Biventricular Pacemakers - Cardiac Resynchronization Therapy for the Treatment of Heart Failure
740 Blepharoplasty Blepharoptosis repair and Brow ptosis repair
097 Bone Morphogenetic Protein
549 Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
006 Botulinum Toxin Injections SP
493 Breast Duct Endoscopy
284 Bronchial Thermoplasty
313 Bronchial Valves
503 CA-125
287 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
916 Cardiac Rehabilitation in the Outpatient Setting
664 Cardiovascular Risk Panels
219 Carotid Stent Placemen
141 Catheter Ablation as Treatment for Atrial Fibrillation
122 Chelation Therapy
732 Chemical Peels
066 Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
942 Chimeric Antigen Receptor Therapy for Multiple Myeloma ABECMA (Idecabtagene Vicleucel)
904 Chromoendoscopy as an Adjunct to Colonoscopy
121 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
019 CNS Stimulants and Psychotherapeutic Agents
478 Cochlear Implant
178 Complementary Medicine
662 Composite Tissue Allotransplantation of the Hand and Face
705 Compound Medications Exclusion Drug List
579 Compounded Medications
594 Computer-Assisted Navigation Orthopedic Procedure
618 Confocal Laser Endomicroscopy
107 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems
407 Continuous Passive Motion in the Home Setting
510 Cooling Devices Used in the Outpatient Setting
905 Corneal Collagen Cross-linking
002 Cox II Inhibitor Drugs
362 Cranial Electrotherapy Stimulation and Auricular Electrostimulation
260 Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
843 Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis
633 Cryosurgical Ablation of Primary or Metastatic Liver Tumors
271 Decompression of the Intervertebral Disc Using Laser Energy - or Radiofrequency Coblation - Nucleoplasty
473 Deep Brain Stimulation
463 Dermatologic Applications of Photodynamic Therapy
041 Diabetes Step Therapy
264 Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology
352 Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
320 Diagnosis and Treatment of Sacroiliac Joint Pain
139 Diagnostic Laboratory Services
593 Diaphragmatic Phrenic Nerve and Diaphragm Pacing Systems
175 Digital Health Technologies Diagnostic Applications
947 Digital Health Therapies for Attention Deficit
411 Directory of Documents
338 Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant
918 Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
049 Drug Management & Retail Pharmacy Prior Authorization Policy
251 Drug Management and Prior Authorization
674 Drug Testing in Pain Management and Substance Use Disorder Treatment
408 Drugs for Cystic Fibrosis
572 Drugs for Weight Loss
164 Dry Hydrotherapy for chronic pain conditions
792 Dry Needling and Trigger Point Injections for Myofascial Pain
842 Durable Medical Equipment DME
263 Dynamic Posturography
195 Dynamic Spinal Visualization and Vertebral Motion Analysis
023 E Form medication prior auth instruction
499 Electrical Bone Growth Stimulation of the Appendicular Skeleton
157 Electrical Stimulation Devices for Psychiatric and Neurological Conditions
302 Electrical Stimulation for the Treatment of Arthritis
498 Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
203 Electromagnetic Navigation Bronchoscopy
701 Electromyography and Nerve Conduction Studies
655 Electrostimulation and Electromagnetic Therapy for Treating Wounds
009 Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm
928 Elzonris Prior Authorization Request Form MP 009
648 End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema
715 Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
218 Endoscopic Radiofrequency Ablation or Cryoablation for Barretts Esophagus
180 Endothelial Keratoplasty
098 Endovascular Grafts for Abdominal Aortic Aneurysms
323 Endovascular Procedures for Intracranial Arterial Disease - Atherosclerosis and Aneurysms
233 Endovascular Stent Grafts for Disorders of the Thoracic Aorta
730 Endovascular Therapies for Extracranial Vertebral Artery Disease
649 Enhanced External Counterpulsation - EECP - for Chronic Stable Angina or Congestive Heart Failure
162 Entyvio ( Vedolizumab ) Policy
690 Epidural Steroid Injections for Neck and Back Pain
492 Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management - Ductal Lavage and Suction Collection Systems
262 Erythropoietin Recombinant Human
087 Esketamine Nasal Spray (SpravatoTM) and Intravenous Ketamine for Mental Health Conditions
069 Esophageal pH Monitoring
581 Evaluation of Biomarkers for Alzheimer Disease
726 Extracorporeal Membrane Oxygenation
248 Extracorporeal Photopheresis
081 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
613 Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
174 Facet Arthroplasty
140 Facet Joint Denervation
556 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
329 Fecal Calprotectin Testing
682 Fecal Microbiota Transplantation
113 Fentanyl, oral-transmucosal
341 Flow Cytometry for Cell Analysis
733 Focal Treatments for Prostate Cancer
201 Functional Neuromuscular Electrical Stimulation
371 Gas Permeable Scleral Contact Lens pdf.pdf
636 Gastric Electrical Stimulation
189 Gender Affirming Services (Transgender Services)
215 Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel
911 Gene Therapy for Inherited Retinal Dystrophy Luxturna
146 Ground Ambulance
257 Growth Hormone and Insulin-like Growth Factor
546 Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery
063 Heart Failure and Hypertrophic Cardiomyopathy (HCM) Policy
269 Heart Lung Transplant
197 Heart Transplant
076 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
150 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
192 Hematopoietic Cell Transplantation for Autoimmune Diseases
074 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
212 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
205 Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
204 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
207 Hematopoietic Cell Transplantation for Hodgkin Lymphoma
191 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
143 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
075 Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome
181 Hematopoietic Cell Transplantation for Primary Amyloidosis
208 Hematopoietic Cell Transplantation for Solid Tumors of Childhood
247 Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors
322 Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
697 HETLIOZ tasimelteon
032 High-Sensitivity C-Reactive Protein
046 Hip Resurfacing
560 Hippotherapy
224 Home Cardiorespiratory Monitoring
430 Home Infusion Therapy Prior Authorization Form
296 Home Total Parenteral Nutrition TPN
016 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
360 Human Anti hemophilic Factor
653 Hyperbaric Oxygen Therapy
048 Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
131 Hypoactive Sexual Desire Disorder (HSDD) Policy
555 Identification of Microorganisms Using Nucleic Acid Probe
240 Image-Guided Minimally Invasive Decompression for Spinal Stenosis
182 Immune Cell Function Assay in Solid Organ Transplantation
004 Immune Modulating Drugs
310 Immunoglobulins Policy
010 Immunomodulators for Skin Conditions
479 Implantable Bone-Conduction and Bone-Anchored Hearing Aids
070 Implantable Cardioverter Defibrillator
521 In Vivo Analysis of Colorectal Polyps
440 Influenza Drugs Tamiflu and Relenza
100 Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates
017 Injectable Asthma Medications
471 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
071 Injectable Specialty Medication Coverage
427 Injections for Osteroarthritis
332 Insulin Delivery Devices
532 Insulin Potentiation Therapy
509 Interferential Stimulation for Treatment of Pain
052 Interferons Alpha and Gamma
584 Interspinous and Interlaminar Stabilization-Distraction Devices - Spacers
436 Interspinous Fixation - Fusion Devices
073 Intracellular Micronutrient Analysis
610 Intraocular Radiation Therapy for Age-Related Macular Degeneration
211 Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
291 Intravenous Anesthetics for the Treatment of Chronic Pain
171 Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
272 Intravitreal and Punctum Corticosteroid Implants
095 Iontophoresis and Phonophoresis as a Transdermal Technique for Drug Delivery
324 Islet Transplantation
631 Isolated Small Bowel Transplant
196 Kidney Transplant
244 Laparoscopic andTranscervical Techniques for the Myolysis of Uterine Fibroids
948 Laser Interstitial Thermal Therapy for Neurological Conditions
461 Laser Treatment of Active Acne
562 Laser Treatment of Onychomycosis
038 Leadless Cardiac Pacemakers
334 Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
589 Leukocyte Histamine Release Test
465 Lipid Apheresis
198 Liver Transplant and Combined Liver-Kidney Transplant
522 Low-Level Laser Therapy
015 Lung and Lobar Lung Transplant
364 Lung Volume Reduction Surgery for Severe Emphysema
483 Manipulation under Anesthesia
365 Manual and Power Operated Wheelchairs
434 Massachusetts Standard Form for Medication Prior Authorization Requests
163 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
524 Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
558 Measurement of Lipoprotein-Associated Phospholipase A2 - Lp-PLA2 - in the Assessment of Cardiovascular Risk
917 Measurement of Serum Antibodies to Selected Biologic Agents
033 Med UM Policy
379 Medical and Surgical Management of Obesity including Anorexiants
034 Medical Benefit Prior Authorization Medication List
999 Medical Policy Updates
350 Medical Technology Assessment Guidelines
400 Medical Technology Assessment NonCovered Services
923 Medicare Advantage High Technology Radiology & Sleep Disorder Management Redirect
132 Medicare Advantage Management
020 Medicare Advantage Part B Step Therapy
125 Medicare Advantage Part B Utilization Management
442 Medicare Part D Coverage Determination Request Form
083 Medications for Sickle Cell and Beta Thalassemia
453 Melanoma Vaccines
110 Meniscal Allografts and Other Meniscal Implants
274 Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction
840 Methotrexate Step Therapy
133 Microprocessor Controlled Prostheses for the Lower Limb
912 Microwave Tumor Ablation
450 Mineral Density Studies
744 Minimally Invasive and surgical treatment options for Benign Prostatic Hyperplasia
029 Molecular Testing in the Management of Pulmonary Nodules
154 Monitored Anesthesia Care - MAC
243 MRI-Guided Focused Ultrasound - MRgFUS
677 Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis
249 Multimarker Serum Testing Related to Ovarian Cancer
839 Multiple Sclerosis Step Therapy
748 Multispectral Digital Skin Lesion Analysis
711 Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
062 Mupirocin Step Policy
112 Myocardial Strain Imaging
576 Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure
227 Myoelectric Prosthetic and Components for the Upper Limb
596 Navigated Transcranial Magnetic Stimulation
543 Negative Pressure Wound Therapy in the Outpatient Setting
393 Nerve Fiber Density Measurement
590 Nerve Graft in Association with Radical Prostatectomy
914 Neural Therapy
515 Neurofeedback
151 Neuropsychological and Psychological Testing
005 New Drug Approval Program
462 Non pharmacologic Treatment of Rosacea
691 Non-Invasive Vascular Studies - Duplex Scans
657 Noncontact Ultrasound Treatment for Wounds
433 Noncovered Drug List
921 Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
123 Nononcologic Uses of Rituximab
283 Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
745 Nutrient - Nutritional Panel Testing
007 Obstetrical Ultrasound and Ultrasound for Family Planning
237 Occipital Nerve Stimulation
454 Oncologic Applications of Photodynamic Therapy, Including Barretts Esophagus
409 Oncology Drugs
356 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation - Maze and Related Procedures
346 Ophthalmic Prostaglandins
053 Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma
102 Opioid Medication Management
915 Optical Coherence Tomography for Imaging of Coronary Arteries
084 Optical Coherence Tomography of the Anterior Eye Segment
737 Orthopedic Applications of Platelet-Rich Plasma
254 Orthopedic Applications of Stem Cell Therapy
611 Orthoptic Training for the Treatment of Vision or Learning Disabilities
550 Orthotics for Progressive Scoliosis
120 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
369 Ostomy Supplies
660 Outpatient Cognitive Rehabilitation
158 Outpatient Pediatric Pain Rehabilitation Centers
072 Outpatient Prior Authorization Code List
423 Outpatient Psychotherapy
136 Outpatient Pulmonary Rehabilitation
266 Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome
170 Overactive Bladder Medications
517 Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain
045 Pathogen Panel Testing
721 Patient-Actuated End Range Motion Stretching Devices
706 Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty
470 Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence
485 Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation
922 Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders
172 Percutaneous Electrical Nerve Stimulation - PENS - and Percutaneous Neuromodulation Therapy - PNT
482 Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation
583 Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction
484 Percutaneous Vertebroplasty and Sacroplasty
513 Peripheral Subcutaneous Field Stimulation
451 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
344 Pharmacy Hepatitis C Medication Management
051 Pharmacy Specialty List
036 Phosphodiesterase Type-5 Inhibitors for Pulmonary Arterial Hypertension
607 Photocoagulation of Macular Drusen
599 Photodynamic Therapy for Choroidal Neovascularization
059 Phototherapy PUVA UV-B and Targeted Phototherapy
955 Phrenic Nerve Stimulation for Central Sleep Apnea
466 Plasma Exchange
068 Plastic Surgery
528 Plugs for Fistula Repair
354 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
541 Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
718 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
047 Preauthorization Request Form for 379 Surgical Management of Obesity Policy
927 Preauthorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain for MP 320
926 Preauthorization Request Form for Gene Therapy for Inherited Retinal Dystrophy
057 Pregabalin (Lyrica and Lyrica CR)
088 Preimplantation Genetic Testing
413 Preventive Screening Tests
952 Prior Authorization Request Form for Artificial Intervertebral Disc Cervical Spine MP 585
942 Prior Authorization Request Form for CAR T-Cell Therapy Services for Multiple Myeloma ABECMA (Idecabtagene Vicleucel)
945 Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (Brexucabtagene Autoleucel)
925 Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel) MP 066
944 Prior Authorization Request Form for CAR T-Cell Therapy Services for Follicular Lymphoma (Axicabtagene Ciloleucel)
940 Prior Authorization Request Form for CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) MP 066
941 Prior Authorization Request Form for CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel)
924 Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma
845 Prior Authorization Request Form for Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems
902 Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189
094 Prior Authorization Request Form for Esketamine Nasal Spray and Intravenous Ketamine for Mental Health Conditions
901 Prior Authorization Request Form for Gender Affirming Services (Transgender Services) MP 189
216 Prior Authorization Request Form for Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel
973 Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb MP 227
160 Prior Authorization Request Form for Scenesse MP 077
956 Prior Authorization Request Form for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease MP 920
085 Prior Authorization Request Form for Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy MP 008
148 Prior Authorization Request Form for Zulresso (Brexanalone) for the Treatment of Postpartum Depression
652 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
183 Prolotherapy
709 Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer
030 Proton Pump Inhibitors
937 Quality Care Cancer Program (Radiation Oncology)
938 Quality Care Cancer Program (Radiation Oncology) CPT and HCPCS Codes
554 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit Hyperactivity Disorder
258 Quantitative Sensory Testing
292 Radioembolization for Primary and Metastatic Tumors of the Liver
259 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
794 Radiofrequency Ablation of Peripheral Nerves to Treat Pain
286 Radiofrequency Ablation of Primary or Metastatic Liver Tumors
919 Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
080 Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
428 Reconstructive Breast Surgery-Management of Breast Implants
703 Reduction Mammaplasty for Breast-Related Symptoms
145 Remote Electrical Neuromodulation for Migraines
064 Repository Corticotropin Injection (H.P Acthar Gel).pdf
716 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
606 Retinal Prosthesis
065 Retinal Telescreening for Diabetic Retinopathy
586 Rhinomanometry and Acoustic or Optical Rhinometry
385 Routine Foot Care and Debridement of Toenails
422 RSV Immunoprophylaxis
153 Sacral Nerve Neuromodulation-Stimulation
307 Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
077 Scenesse afamelanotide for the treatment of Erythropoietic protoporphyria
494 Scintimammography, Breast-Specific Gamma Imaging, and Molecular Breast Imaging
480 Semi-Implantable and Fully Implantable Middle Ear Hearing Aid
659 Sensory Integration Therapy
138 Serological Diagnosis of Celiac Disease
551 Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
290 Serum Biomarker Human Epididymis Protein 4 - HE4
702 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
538 Serum Tumor Markers for Breast and Gastrointestinal Malignancies
078 Sexual Dysfunction Diagnosis and Therapy
156 Shoulder Resurfacing
134 Signal-Averaged Electrocardiography - SAECG
969 Sleep Disorder Management
970 Sleep Disorder Management CPT and HCPCS Codes
632 Small Bowel, Liver, and Multivisceral Transplant
093 Soliris, Ultomiris, Myasthenia Gravis, and Neuromyelitis Optica
304 Special Foods
026 Sphenopalatine Ganglion Block for Headache
472 Spinal Cord and Dorsal Root Ganglion Stimulation
044 Spinal Muscular Atrophy (SMA) Medications
530 ST2 Assay for Chronic Heart Failure
348 Stem-cell Therapy for Peripheral Arterial Disease
800 Steroid-Eluting Sinus Stents
681 Sublingual Immunotherapy with Allergen-specific Extracts - SLIT
299 Subtalar Arthroereisis
105 Supportive Care Treatments for Patients with Cancer
609 Suprachoroidal Delivery of Pharmacologic Agents
695 Surgery for Groin Pain in Athletes
037 Surgical and Debulking Treatments for Lymphedema
661 Surgical and Non-surgical Treatment of Gynecomastia
920 Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease
801 Surgical Deactivation of Headache Trigger Sites
570 Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
176 Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation
130 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
544 Surgical Ventricular Restoration
250 Systems Pathology in Prostate Cancer
035 Temporomandibular Joint Disorder
342 Thermography
321 Threshold Electrical Stimulation as a Treatment of Motor Disorders
345 Topical Testosterone
426 Topical_Ocular_Hydrating_Agents
193 Total Ankle Replacement
280 Total Artificial Hearts and Implantable Ventricular Assist Devices
200 Transanal Endoscopic Microsurgery
392 Transcatheter Aortic-Valve Implantation for Aortic Stenosis
634 Transcatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic Liver Malignancies
692 Transcatheter Mitral Valve Repair
403 Transcatheter Pulmonary Valve Implantation
297 Transcranial Magnetic Stimulation as a Treatment of Depression
003 Transcutaneous Electrical Nerve Stimulation
651 Transmyocardial Revascularization
600 Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization
523 Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
406 Treatment of Hyperhidrosis
267 Treatment of Tinnitus
238 Treatment of Varicose Veins and Venous Insufficiency
604 Trigger Point and Tender Point Injections
167 Tumor Markers for diagnosis and management of cancer
303 Ultrasonographic Evaluation of Skin Lesions
547 Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
497 Ultrasound Accelerated Fracture Healing Device
445 Ultrasound for the Evaluation of Paranasal Sinuses
742 Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral
370 Urological Supplies
060 Uterus Transplantation for Absolute Uterine Factor Infertility
474 Vagus Nerve Stimulation
092 Vascular Endothelial Growth Factor (VEGF) Inhibitors Step Therapy
603 Vertebral Axial Decompression
449 Vertebral Fracture Assessment with Densitometry
305 Vertical Expandable Prosthetic Titanium Rib
024 Vestibular Function Testing
372 Viscocanalostomy and Canaloplasty
675 Vision Services
746 Vitamin D Assay Testing
042 Wearable Cardioverter Defibrillators
577 Whole Body Dual X-Ray Absorptiometry to Determine Body Composition
149 Whole Gland Cryoablation of the Prostate
447 Whole-Body Computed Tomography Scan as a Screening Test
185 Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
306 Wireless Pressure Sensors in Endovascular Aneurysm Repair
008 Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy
147 ZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression

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ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación llamada 1-800-200-4255 (TTY: 711 ).

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ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan Rele 1-800-200-4255 TTY: 711 ).

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참고 : 한국어를 사용하는 경우 언어 지원 서비스를 무료로 사용할 수 있습니다. 신분증에있는 전화 번호 1-800-200-4255 (TTY : 711)로 회원 서비스에 연락하십시오.

ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) κλήση 1-800-200-4255 (TTY: 711 ).

UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze zadzwoń 1-800-200-4255 (TTY: 711 ).

ध्यान दें: य दि  आप ह िन् दी बोलते ह ैं, तो भा षा  सहाय  ता  सेवा एँ, आप के लि ए नि :शुल्क  उपलब्ध ह ैं। सदस्य  सेवा ओं को आपके आई.डी. कार  ्ड पर दि ए गए नंबर पर कॉल करें  कॉल 1-800-200-4255 ( टी .टी .वा ई.: 711).

ધ્યાન આપો:  જો તમે ગુજરા તી બોલતા  હો, તો તમને ભા ષા કીય  સહાય  તા  સેવા ઓ વિ ના  મૂલ્યે  ઉપલબ્ધ છે. તમા રા  આઈડી કાર  ્ડ પર આપેલા  નંબર પર Member Service  ને કૉલ કરો કૉલ કરો 1-800-200-4255 (TTY: 711).

PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card tumawag 1-800-200-4255 (TTY: 711 ).

お知らせ:日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いただけます。ID カードに記載の電話番号を使用してメンバーサービスまでお電話ください 呼び出す 1-800-200-4255(TTY: 711 )。

ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an Anrufen 1-800-200-4255 (TTY: 711 ).

ຂໍ້ຄວນໃສ່ໃຈ: ຖ້າເຈົ້າເວົ້າພາສາລາວໄດ້, ມີການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາໃຫ້ທ່ານໂດຍບໍ່ເສຍຄ່າ. ໂທ ຫາ ຝ່າຍບໍລິການສະ ມາ ຊິກທີ່ໝາຍເລກໂທລະສັບຢູ່ໃນບັດຂອງທ່ານ ໂທ 1-800-200-4255 (TTY: 711).

BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih call 1-800-200-4255 (TTY: 711).

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