| Effective Date | Policy Name | Reviewed Date |
| 8/5/2021 |
Headache and Occipital Neuralgia Treatments
| 2/24/2021 |
| 6/3/2021 |
Genetic Testing for Hereditary Ataxias
| 3/25/2020 |
| 5/6/2021 |
Genetic Testing
| 2/24/2021 |
| 4/14/2021 |
Skin and Tissue Substitutes
| 1/28/2021 |
| 4/2/2021 |
Ambulatory Cardiac Monitoring Devices
| 3/25/2021 |
| 4/1/2021 |
Attention Deficit Hyperactivity Disorder (ADHD) - Diagnosis and Treatment
| 5/28/2020 |
| 4/1/2021 |
Balloon Dilation (Eustachian Tube and Sinus) and Functional Endoscopic Sinus Surgery
| 2/24/2021 |
| 4/1/2021 |
Code Compendium (Laboratory)
| 12/10/2020 |
| 4/1/2021 |
Code Compendium (Miscellaneous)
| 1/28/2021 |
| 4/1/2021 |
Orthotics
| 2/24/2021 |
| 4/1/2021 |
Prosthetics
| 9/23/2020 |
| 4/1/2021 |
Vagus Nerve Stimulation (VNS)
| 10/22/2020 |
| 3/30/2021 |
Cryoablation
| 12/10/2020 |
| 3/25/2021 |
Artificial Intervertebral Disc Replacement
| 3/25/2021 |
| 3/25/2021 |
Autonomic Nerve Function Testing
| 3/25/2021 |
| 3/25/2021 |
Bone Growth Stimulators
| 3/25/2021 |
| 3/25/2021 |
Code Compendium (Cardiovascular)
| 3/25/2021 |
| 3/25/2021 |
Defecography
| 3/25/2021 |
| 3/25/2021 |
Diagnostic Esophagogastroduodenoscopy (EGD) or Esophagascopy (age 59 years or younger)
| 10/22/2020 |
| 3/25/2021 |
Genetic Testing for Breast, Ovarian and Pancreatic Cancer Susceptibility
| 3/25/2021 |
| 3/25/2021 |
Genetic Testing for Diagnosis and Monitoring Cancer Indications and Molecular Profiling
| 3/25/2020 |
| 3/25/2021 |
Genetic Testing for Methylene Tetrahydrofolate Reductase (MTHFR)
| 3/25/2021 |
| 3/25/2021 |
Gynecomastia Surgery
| 3/25/2021 |
| 3/25/2021 |
Home Oximetry Monitoring
| 3/25/2021 |
| 3/25/2021 |
Hyperbaric Oxygen Therapy, Topical Oxygen Therapy
| 3/25/2021 |
| 3/25/2021 |
In Vitro Chemoresistance and Chemosensitivity Assays
| 3/25/2021 |
| 3/25/2021 |
Laser Interstitial Thermal Therapy
| 3/25/2021 |
| 3/25/2021 |
Lymphedema (Diagnosis and Treatment)
| 3/25/2021 |
| 3/25/2021 |
Noninvasive Prenatal Screening
| 10/22/2020 |
| 3/25/2021 |
Proton Beam, Neutron Beam and Carbon Ion Radiation Therapy
| 3/25/2021 |
| 3/25/2021 |
Support Garments, Fabric
| 3/25/2021 |
| 3/25/2021 |
Tinnitus Treatments
| 3/25/2021 |
| 3/25/2021 |
Transcranial Magnetic Stimulation (TMS) and Cranial Electrical Stimulation (CES)
| 3/25/2021 |
| 3/25/2021 |
Urinary Bladder Dysfunction
| 12/10/2020 |
| 3/25/2021 |
Whole Genome/Exome Sequencing and Genome-Wide Association Studies
| 3/25/2021 |
| 3/12/2021 |
Hip, Knee and Shoulder Arthroscopic Surgeries
| 12/10/2020 |
| 3/3/2021 |
Liquid Biopsy
| 1/28/2021 |
| 2/25/2021 |
Genetic Testing for Hereditary Hemochromatosis
| 3/25/2021 |
| 2/24/2021 |
Applied Behavior Analysis
| 2/24/2021 |
| 2/24/2021 |
Autism Spectrum Disorders (ASD) Diagnosis and Treatment
| 2/24/2021 |
| 2/24/2021 |
Comparative Genomic Hybridization/Chromosomal Microarray
| 8/27/2020 |
| 2/24/2021 |
Continuous Passive Motion (CPM) and Mechanical Stretching Devices
| 2/24/2021 |
| 2/24/2021 |
Coronary Artery Calcium Scoring and Coronary Computed Tomography Angiography
| 2/24/2021 |
| 2/24/2021 |
Discography
| 2/24/2021 |
| 2/24/2021 |
Extraosseous Subtalar Joint implantation and Subtalar Arthroereisis
| 2/24/2021 |
| 2/24/2021 |
Fluorescence In Situ (FISH) for Noncancer Indications
| 2/24/2021 |
| 2/24/2021 |
Fusion Imaging
| 8/27/2020 |
| 2/24/2021 |
Gene Expression Profiling
| 4/23/2020 |
| 2/24/2021 |
Genetic Testing
| 2/24/2021 |
| 2/24/2021 |
Genetic Testing for Angelman and Prader-Willi Syndrome
| 4/23/2020 |
| 2/24/2021 |
Genetic Testing for Cancer Susceptibility
| 12/10/2020 |
| 2/24/2021 |
Genetic Testing for Cardiac Conditions
| 8/27/2020 |
| 2/24/2021 |
Genetic Testing for Carrier Screening
| 9/23/2020 |
| 2/24/2021 |
Genetic Testing for Celiac Disease
| 1/28/2021 |
| 2/24/2021 |
Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome
| 4/23/2020 |
| 2/24/2021 |
Genetic Testing for Colorectal Cancer Susceptibility
| 2/24/2021 |
| 2/24/2021 |
Genetic Testing for Cystic Fibrosis
| 8/27/2020 |
| 2/24/2021 |
Genetic Testing for Diagnosis of Noncancer Indications
| 9/23/2020 |
| 2/24/2021 |
Genetic Testing for Disease Risk
| 9/23/2020 |
| 2/24/2021 |
Genetic Testing for Ehlers-Danlos Syndrome
| 5/28/2020 |
| 2/24/2021 |
Genetic Testing for Hereditary Ataxias
| 3/25/2020 |
| 2/24/2021 |
Genetic Testing for Inherited Thrombophilias
| 7/23/2020 |
| 2/24/2021 |
Genetic Testing for Marfan Syndrome and Related Conditions
| 2/24/2021 |
| 2/24/2021 |
Genetic Testing for Mitochondrial Disorders
| 5/28/2020 |
| 2/24/2021 |
Genetic Testing for Muscular Dystrophy and Spinal Muscular Atrophy
| 6/25/2020 |
| 2/24/2021 |
Genetic and Biomarker Testing for Alzheimer Disease
| 7/23/2020 |
| 2/24/2021 |
Headache and Occipital Neuralgia Treatments
| 2/24/2021 |
| 2/24/2021 |
Janus Kinase 2 (JAK2) V617F, Exon 12 -15, Calreticulin (CALR) and MPL Mutation Analysis
| 6/25/2020 |
| 2/24/2021 |
Laboratory Analysis for Prostate Cancer
| 7/23/2020 |
| 2/24/2021 |
Molecular Diagnostic Assays and Breath Testing for Transplant Rejection
| 2/24/2021 |
| 2/24/2021 |
Molecular Diagnostic Testing for Reproductive Health
| 5/28/2020 |
| 2/24/2021 |
Molecular Markers in Fine Needle Aspirates of Thyroid Nodules
| 1/28/2021 |
| 2/24/2021 |
Molecular Testing for HLA B27 for Ankylosing Spondylitis
| 6/25/2020 |
| 2/24/2021 |
Negative Pressure Wound Therapy (NPWT)
| 2/24/2021 |
| 2/24/2021 |
Orthognathic Surgery
| 2/24/2021 |
| 2/24/2021 |
Peripheral Artery Angiography, Rehabilitation and Revascularization - Lower Extremities
| 2/24/2021 |
| 2/24/2021 |
Pharmacogenomics (Pharmacogenetics) - Noncancer Indications
| 4/23/2020 |
| 2/24/2021 |
Pharmacogenomics - Cytochrome P450 Polymorphisms and VKORC1
| 10/22/2020 |
| 2/24/2021 |
Pharmacogenomics and Companion Diagnostics
| 12/10/2020 |
| 2/24/2021 |
Preimplantation Genetic Testing
| 9/23/2020 |
| 2/24/2021 |
Prenatal Invasive Diagnostic Genetic Testing
| 2/24/2021 |
| 2/24/2021 |
Prophylactic Mastectomy
| 2/24/2021 |
| 2/24/2021 |
Transcatheter Valve Procedures
| 2/24/2021 |
| 2/24/2021 |
Tumor Markers for Diagnosis and Monitoring of Cancer
| 1/28/2021 |
| 2/24/2021 |
Ventricular Assist Device (VAD) Total Artificial Heart (TAH)
| 2/24/2021 |
| 2/23/2021 |
Cognitive Rehabilitation
| 6/25/2020 |
| 2/8/2021 |
Breast Reconstruction
| 5/28/2020 |
| 2/3/2021 |
Biofeedback
| 12/10/2020 |
| 1/28/2021 |
Acne Treatments
| 1/28/2021 |
| 1/28/2021 |
Airway Clearance Devices
| 4/23/2020 |
| 1/28/2021 |
Allergy Testing
| 1/28/2021 |
| 1/28/2021 |
Allograft Transplantation of the Knee
| 1/28/2021 |
| 1/28/2021 |
Bariatric Surgery
| 1/28/2021 |
| 1/28/2021 |
Benign Prostatic Hyperplasia (BPH) Treatments
| 1/28/2021 |
| 1/28/2021 |
Bone Graft Substitutes
| 1/28/2021 |
| 1/28/2021 |
Cardiac Catheterization
| 1/28/2021 |
| 1/28/2021 |
Cardiac Electrophysiological Studies and Cardiac Catheter Ablation
| 1/28/2021 |
| 1/28/2021 |
Cardiac Stents and Angioplasty
| 1/28/2021 |
| 1/28/2021 |
Code Compendium (Musculoskeletal and Neurologic)
| 1/28/2021 |
| 1/28/2021 |
Code Compendium (Ophthalmology)
| 1/28/2021 |
| 1/28/2021 |
Colorectal Cancer Screening
| 12/10/2020 |
| 1/28/2021 |
Durable Medical Equipment
| 1/28/2021 |
| 1/28/2021 |
Electric Tumor Treatment Fields
| 1/28/2021 |
| 1/28/2021 |
Hammer Toe Surgical Treatments
| 1/28/2021 |
| 1/28/2021 |
Microwave Thermotherapy
| 9/23/2020 |
| 1/28/2021 |
Noninvasive Tests for Hepatic Fibrosis
| 1/28/2021 |
| 1/28/2021 |
Ultraviolet Light (Including Laser) Therapy for Skin Conditions
| 8/27/2020 |
| 1/28/2021 |
Varicose Vein Treatments
| 1/28/2021 |
| 1/27/2021 |
Fecal Incontinence Evaluation and Treatments
| 12/10/2020 |
| 1/22/2021 |
Acupuncture
| 8/27/2020 |
| 1/22/2021 |
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
| 4/23/2020 |
| 1/22/2021 |
Electrical Stimulators for Pain and Nausea/Vomiting
| 4/23/2020 |
| 1/22/2021 |
Fecal Microbiota Transplantation (FMT)
| 7/23/2020 |
| 1/22/2021 |
Gastric Pacing
| 7/23/2020 |
| 1/22/2021 |
Hyperhidrosis Treatments
| 4/23/2020 |
| 1/22/2021 |
Infertility Evaluation and Treatment
| 5/28/2020 |
| 1/22/2021 |
Inhaled Nitric Oxide
| 12/10/2020 |
| 1/22/2021 |
Mobility Assistive Devices (Wheelchairs)
| 6/25/2020 |
| 1/22/2021 |
Obstructive Sleep Apnea (OSA) and Other Sleep Related Breathing Disorders Nonsurgical Treatments
| 8/27/2020 |
| 1/22/2021 |
Obstructive Sleep Apnea (OSA) and Other Sleep Related Breathing Disorders Surgical Treatments
| 8/27/2020 |
| 1/22/2021 |
Reduction Mammaplasty
| 7/23/2020 |
| 1/1/2021 |
Breast Imaging
| 7/23/2020 |
| 1/1/2021 |
Chronic Vertigo Evaluation and Treatment
| 9/23/2020 |
| 1/1/2021 |
Cosmetic Surgery, Reconstructive Surgery, Scar Revision
| 8/27/2020 |
| 1/1/2021 |
Drug Testing
| 9/23/2020 |
| 1/1/2021 |
Gender Reassignment Surgery
| 9/23/2020 |
| 1/1/2021 |
Injections for Chronic Pain Conditions
| 7/23/2020 |
| 1/1/2021 |
Intraoperative Neurological Monitoring
| 4/23/2020 |
| 1/1/2021 |
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty
| 9/23/2020 |
| 1/1/2021 |
Rhinoplasty-Septoplasty
| 6/25/2020 |
| 1/1/2021 |
Serological and Fecal Testing for Inflammatory Bowel Disease (IBD)
| 8/27/2020 |
| 1/1/2021 |
Tissue Doppler Imaging (Tissue Doppler Echocardiography, Tissue Doppler
| 7/23/2020 |
| 12/10/2020 |
Cardiovascular Disease (CVD) Risk Testing
| 12/10/2020 |
| 12/10/2020 |
Carpal Tunnel Syndrome Surgical Treatments
| 12/10/2020 |
| 12/10/2020 |
Electrothermal Intradiscal Therapies
| 12/10/2020 |
| 12/10/2020 |
Extended Ophthalmoscopy
| 12/10/2020 |
| 12/10/2020 |
Manipulation Under Anesthesia
| 12/10/2020 |
| 12/10/2020 |
Multianalyte Assays with Algorithmic Analyses (MAAAs)
| 10/22/2020 |
| 12/10/2020 |
Plasmapheresis
| 12/10/2020 |
| 12/10/2020 |
Skin Lesion Surveillance Technologies
| 12/10/2020 |
| 12/10/2020 |
Speech Therapy
| 12/10/2020 |
| 12/10/2020 |
Spinal Fusion Surgery
| 12/10/2020 |
| 12/10/2020 |
Temporomandibular Joint Disorders (TMJ/TMD)
| 12/10/2020 |
| 12/10/2020 |
Ultrasound Therapy for Wound Healing
| 12/10/2020 |
| 10/22/2020 |
Carotid Revascularization
| 10/22/2020 |
| 10/22/2020 |
Continuous Glucose Monitoring Systems and Insulin Pumps
| 10/22/2020 |
| 10/22/2020 |
Elective Aorta and Iliac Artery Aneurysm Repair
| 10/22/2020 |
| 10/22/2020 |
Endobronchial Valves for the Treatment of Severe Emphysema
| 10/22/2020 |
| 10/22/2020 |
Glaucoma Emerging Treatments
| 4/23/2020 |
| 10/22/2020 |
Hyperthermia Treatment for Cancer (Local, Regional and Whole Body)
| 10/22/2020 |
| 10/22/2020 |
Lung Cancer Screening
| 10/22/2020 |
| 10/22/2020 |
Multiplex Pathogen Testing and Next Generation Sequencing for Infectious Disease
| 10/22/2020 |
| 10/22/2020 |
Neuroablative Techniques for Chronic Pain
| 10/22/2020 |
| 10/22/2020 |
Noninvasive Home Ventilators
| 10/22/2020 |
| 10/22/2020 |
Ocular Surface Disease Diagnosis and Treatments
| 10/22/2020 |
| 10/22/2020 |
Ovarian Vein and - or Internal Iliac Vein Embolization
| 10/22/2020 |
| 10/22/2020 |
Panniculectomy, Abdominoplasty, Abdominal Contouring
| 10/22/2020 |
| 10/22/2020 |
Pudendal Neuralgia Treatments
| 10/22/2020 |
| 10/22/2020 |
Pulmonary Rehabilitation
| 10/22/2020 |
| 10/1/2020 |
Speech Generating Devices, Voice Prostheses
| 7/23/2020 |
| 9/23/2020 |
Ablation Techniques and Extracorporeal Shock Wave Therapy for Musculoskeletal Indications and Soft Tissue Wounds
| 9/23/2020 |
| 9/23/2020 |
Actinic Keratoses Treatments
| 9/23/2020 |
| 9/23/2020 |
Cardiac Rehabilitation
| 9/23/2020 |
| 9/23/2020 |
Clinical Trials
| 9/23/2020 |
| 9/23/2020 |
Cold Therapy Devices/ Heating Devices/ Combined Heat and Cold Therapy Devices
| 9/23/2020 |
| 9/23/2020 |
Hip Arthroplasty
| 9/23/2020 |
| 9/23/2020 |
Left Atrial Appendage and Cardiac Structural Defect Closure for Stroke Prevention
| 9/23/2020 |
| 9/23/2020 |
Osteochondral and Subchondral Defects Surgery
| 9/23/2020 |
| 9/23/2020 |
Radiofrequency Tumor Ablation
| 9/23/2020 |
| 9/23/2020 |
Scanning Computerized Ophthalmic Diagnostic Imaging
| 9/23/2020 |
| 9/23/2020 |
Thyroid Surgeries (Thyroidectomy and Lobectomy)
| 9/23/2020 |
| 9/23/2020 |
Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications
| 9/23/2020 |
| 8/27/2020 |
Allergy Treatments
| 8/27/2020 |
| 8/27/2020 |
Capsule Endoscopy
| 8/27/2020 |
| 8/27/2020 |
Complementary and Alternative Medicine
| 8/27/2020 |
| 8/27/2020 |
Continuous Ambulatory Blood Pressure Monitoring
| 8/27/2020 |
| 8/27/2020 |
Electrical Stimulators - Diaphragmatic/Phrenic Nerve, Functional and Neuromuscular
| 8/27/2020 |
| 8/27/2020 |
Immunoassay Testing for Rupture of Membranes (ROM) in Pregnancy
| 8/27/2020 |
| 8/27/2020 |
Intraocular Lens (IOL) Implants
| 8/27/2020 |
| 8/27/2020 |
Knee Arthroplasty
| 8/27/2020 |
| 8/27/2020 |
Prostatectomy
| 8/27/2020 |
| 8/27/2020 |
Shoulder Arthroplasty
| 8/27/2020 |
| 8/27/2020 |
Sleep Studies, Adults
| 7/23/2020 |
| 8/27/2020 |
Spinal Decompression Surgery
| 8/27/2020 |
| 8/27/2020 |
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
| 8/27/2020 |
| 7/23/2020 |
Benign Skin Lesion Treatments
| 7/23/2020 |
| 7/23/2020 |
Bronchial Thermoplasty
| 7/23/2020 |
| 7/23/2020 |
Chiropractic Care
| 7/23/2020 |
| 7/23/2020 |
Deep Brain Stimulation and Cortical Brain Stimulation
| 7/23/2020 |
| 7/23/2020 |
Gastrointestinal (GI) Motility Monitoring
| 7/23/2020 |
| 7/23/2020 |
Implantable Hearing Devices
| 4/23/2020 |
| 7/23/2020 |
Interspinous Process Decompression Spacers
| 7/23/2020 |
| 7/23/2020 |
Physical Therapy (PT) and Occupational Therapy (OT)
| 7/23/2020 |
| 7/23/2020 |
Plantar Fasciitis Treatments
| 7/23/2020 |
| 7/23/2020 |
Rheumatoid Arthritis: Biologic Markers and Pharmacologic Assessment
| 7/23/2020 |
| 7/23/2020 |
Uterine Fibroid Surgical Treatments
| 7/23/2020 |
| 6/25/2020 |
Bunion and Bunionette Surgical Treatments
| 6/25/2020 |
| 6/25/2020 |
Direct-to-Consumer (DTC) Laboratory Testing and Mobile Health (mHealth) Applications
| 6/25/2020 |
| 6/25/2020 |
Dynamic Spinal Stabilization Devices
| 6/25/2020 |
| 6/25/2020 |
Exhaled Breath Tests
| 6/25/2020 |
| 6/25/2020 |
Home Health
| 6/25/2020 |
| 6/25/2020 |
Irreversible Electroporation (NanoKnife)
| 6/25/2020 |
| 6/25/2020 |
Platelet Derived Growth Factors for Wound Healing
| 6/25/2020 |
| 6/25/2020 |
Transplantation, Solid Organ or Stem Cell
| 6/25/2020 |
| 6/23/2020 |
Cardioverter Defibrillators/Cardiac Resynchronization Therapy
| 4/23/2020 |
| 5/28/2020 |
Achalasia and Gastroesophageal Reflux Disease (GERD) Treatments
| 5/28/2020 |
| 5/28/2020 |
Athletic Pubalgia Surgery
| 5/28/2020 |
| 5/28/2020 |
Bone Density Measurement
| 5/28/2020 |
| 5/28/2020 |
Brachytherapy
| 5/28/2020 |
| 5/28/2020 |
Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds
| 5/28/2020 |
| 5/28/2020 |
Implantable Infusion Pumps for Pain or Spasticity
| 5/28/2020 |
| 5/28/2020 |
Karyotyping for Diagnosis of Noncancer Indications
| 5/28/2020 |
| 5/28/2020 |
Keratoconus Surgical Treatments
| 5/28/2020 |
| 5/28/2020 |
Low-Level Laser Therapy (Cold Laser Therapy), High-Power Laser Therapy
| 5/28/2020 |
| 5/28/2020 |
Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography
| 5/28/2020 |
| 5/28/2020 |
Recurrent Pregnancy Loss
| 5/28/2020 |
| 5/28/2020 |
Spinal Cord Stimulators
| 5/28/2020 |
| 5/28/2020 |
Tilt Table Testing
| 5/28/2020 |
| 4/23/2020 |
Cytological Examination and Fiberoptic Ductoscopy for Breast Cancer Screening
| 4/23/2020 |
| 4/23/2020 |
Erectile Dysfunction and Peyronie's Disease Treatments
| 4/23/2020 |
| 4/23/2020 |
Home Births
| 4/23/2020 |
| 4/23/2020 |
Intensity Modulated Radiation Therapy (IMRT)
| 4/23/2020 |
| 4/23/2020 |
Leadless Cardiac Pacemakers
| 4/23/2020 |
| 4/23/2020 |
Monochromatic Infrared Energy Therapy
| 4/23/2020 |
| 4/23/2020 |
Pneumatic Compression Pumps
| 4/23/2020 |