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Epcoritamab-bysp (e.g., Epkinly)
1st Trimester Detection Down Syndrome- Fetal US Markers with Maternal Serum
Abatacept (e.g., Orencia)
Ablation of Soft Tissue for Musculoskeletal Conditions
Ablation Procedures for Morton and Other Peripheral Neuromas
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
Actigraphy
Adoptive Immunotherapy
Ado-Trastuzumab Emtansine for Treatment of HER-2 Positive Malignancies
Advanced Transcutaneous Electrical Stimulation
Afamelanotide (e.g., Scenesse™)
Airway Clearance Devices
Alemtuzumab (Lemtrada)
Alglucosidase alfa (e.g., Lumizyme)
Allo HSCT for Myelodysplastic Disease
Allogeneic Pancreas Transplant
Allogenic processed thymus tissue-agdc (e.g., Rethymic)
Allograft Injection for Degenerative Disc Disease
Alpha-1 Proteinase Inhibitor Therapy
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Amivantamab (e.g., Rybreyant™)
Amniocentesis_Chorionic Villus Sampling-Detect Fetal Hereditary/Chromos Abn
Amniotic Membrane and Amniotic Fluid Injections
Anifrolumab-fnia (e.g., Saphnelo)
Antigen Leukocyte Antibody Test (ALCAT)
Antineoplaston Cancer Therapy
Anti-PD-1 Therapy (e.g., Nivolumab)(e.g., Durvalumab)(e.g., Cemiplimab)
Aqueous Shunts and Stents for Glaucoma
Artificial Intervertebral Disc: Lumbar
Asfotase alfa (e.g., Strensiq®)
Asparagine Specific Enzymes (e.g., Rylaze, Asparlas, Oncaspar)
Atezolizumab (e.g., Tecentriq)
Auditory Brainstem Implant
Autism Spectrum Disorder, Applied Behavior Analysis
Autografts and Allografts- Trtmt of Focal Articular Cartilage
Autologous Chondrocyte Implantation-Focal Articular Cartilage Lesions
Autologous HSCT for Malignant Astrocytomas and Gliomas
Automated Ambulatory Blood Pressure Monitoring for Hypertension
Automated Whole Breast Ultrasound
Autonomic Nervous System Testing
Avalglucosidase alfa-ngpt (e.g., Nexviazyme)
Avancincaptad pegol (e.g., Izervay)
Avelumab (Bavencio™)
Axial Lumbosacral Interbody Fusion
Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema
Balloon Dilation of the Eustachian Tube
Balloon Ostial Dilation (Balloon Sinuplasty)_for Tx Sinusitis
Baroreflex Stimulation Devices
Belantamab mafodotin-blmf e.g., Blenrep)
Belimumab (e.g., Benlysta)
Benralizumab (e.g., Fasenra®)
Beremagene Geperpavec-svdt (e.g., Vyjuvek)
Bevacizumab (Avastin™) for Oncologic Indications
Bevacizumab (e.g., Avastin)
Bezlotoxumab (e.g., Zinplava™)
Bimatoprost (Durysta™)
Bioengineered Skin and Soft Tissue Substitutes
Bioimpedance Devices for Detection and Management of Lymphedema
Biomarker, M_Polyglutamates_Predict Response_ Arthritis (Avise® PG)
Biomarkers for Alzheimer Disease
Biventricular Pacemakers for Treatment of Congestive Heart Failure
Blepharoplasty/Blepharoptosis and Ectropion/Entropion Repair
Blinatumomab (e.g., Blincyto)
Bone Growth Stimulation, Electrical, Axial Skeleton and SI Joint Fusion
Bone Markers (Collagen Crosslinks as Biological Markers of Bone Turnover)
Bone Mineral Density Study (Densitometry, DEXA, DXA)
Bone Morphogenetic Protein
Bortezomib (e.g., Velcade)
Botulinum Toxin (e.g., Botox)
Brachytherapy_Prostate Cancer, Low-Dose (eg Permanently Implanted Seeds)
Breast Brachytherapy and Accelerated Breast Irradiation
Brentuximab (Adcetris™)
Brexanolone (e.g., Zulresso™)
Bronchial Thermoplasty
Burosumab-twza (e.g., Crysvita®)
Cabazitaxel (e.g., JEVTANA)
Cabotegravir extended-release (e.g., Apretude)
Cabotegravir-rilpivirine (e.g., Cabenuva)
Canakinumab (e.g., Ilaris™)
Caplacizumab-yhdp (Cablivi)
Capsaicin (e.g., Qutenza)
Cardiac and Coronary Artery Computed Tomography, CCTA FFR, CT CAC
Cardiac Hemodynamic Monitoring-Mgmt of Heart Failure in OP Setting
Cardiac Rehabilitation in the Outpatient Setting
Cardiovascular Risk Panels
Carfilzomib (e.g., Kyprolis)
CAR-T
Catheter Ablation as Treatment of Atrial Fibrillation
Cellular Immunotherapy for Prostate Cancer, Sipuleucel-T Therapy
Cerliponase Alfa (e.g., Brineura™)
Cervical Disc Arthroplasty (Cervical Artificial Intervertebral Disc)
Cervical Traction Devices for Home Use
Cetuximab (Erbitux™)
Chelation Therapy
Chemical Peels
Chromoendoscopy as an Adjunct to Colonoscopy
Chronic Intermittent Intravenous Insulin Therapy (CIIIT)
Chronic Pain Management Programs
Cipaglucosidase alfa-atga (e.g., Pombiliti)
Circ Tumor DNA_Circ Tumor Cells for Cancer Mngmt (Liquid Biopsy)
Closure Devices for PFO and ASD or VSD
Cochlear Implant
Cognitive Rehabilitation
Cold and Heat Therapy
Composite Tissue Allotransplantation (CTA) of the Hand and/or Face
Computed Tomography (CT) Perfusion Imaging of the Brain
Computer-Assisted Navigation for Orthopedic Procedure
Confocal Laser Endomicroscopy
Continuous Local Anesthetic Infusion Pumps (Disposable Pain Pumps)
Copanlisib (Aliqopa)
Corneal Collagen Cross-linking
Corneal Topography (Photokeratoscopy)
Covid-19 Monoclonal Antibody Therapy
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation
Crizanlizumab (e.g., Adakveo™)
Cryoablation of Tumors in the Kidney, Lung, Breast, Pancreas, or Bone
Cryoablation, RFA, Laser Ablation for Tx of Chronic Rhinitis
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
CT Scans for Lung Cancer Screening
Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy
Daratumumab (e.g., Darzalex) / Daratumumab and Hyaluronidase-fihi
Deep Brain Stimulation
Delandistrogene moxeparvovec-rokl (e.g., Elevidys)
Denosumab (e.g., XGEVA™ and Prolia™)
Dermatologic Applications of Photodynamic Therapy
Dexamethasone intraocular suspension (e.g., DEXYCU®)
Dexmedetomidine (e.g., Igalmi)
Diagnosis and Minimally Invasive Treatment of Sacroiliac Joint Pain
Diagnosis of Obstructive Sleep Apnea Syndrome
Difelikefalin (e.g., Korsuva)
Digital Breast Tomosynthesis
Digital Health Technologies: Diagnostic Applications
Digital Health Technologies: Therapeutic Applications
Digital Health Therapies for Attention Deficit/Hyperactivity Disorder
Digital Health Therapies for Substance Abuse
Digital Motion X-ray for Musculoskeletal Conditions
Discectomy, Percutaneous and P. Endoscopic, Manual, Automated or Laser
Dopamine Transporter Imaging with Single Photon Emission CD (DAT-SPECT)
Dostartlimab (e.g., Jemperli)
Dry Hydrotherapy for Chronic Pain Conditions
Dry Needling of Myofascial Trigger Points
Dynamic Posturography
Dynamic Spinal Visualization and Vertebral Motion Analysis
Eculizumab (e.g., Soliris)
Edaravone (e.g., Radicava)
Efgartigimod (e.g., Vyvgart)
Electrical and Electromagnetic Stimulation for the Treatment of Arthritis
Electrical Bone Growth Stimulation of the Appendicular Skeleton
Electromagnetic Navigation Bronchoscopy
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Electrostimulation and Electromagnetic Therapy for Treating Wounds
Elivaldogene autotemcel (e.g., Skysona)
Elotuzumab (e.g., Empliciti™)
Elranatamab-bcmm (e.g., Elrexfio)
Emapalumab-lzsg (e.g., Gamifant®)
Endobronchial Brachytherapy
Endobronchial Valves
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus
Endothelial Function Test, Nonivasive
Endothelial Keratoplasty
Endovascular Procedures, Intracranial Arterial Dz & Extracranial Vertebral
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
Endovascular Stent Grafts for Disorders for the Thoracic Aorta
Enfortumab vedotin-ejfv (e.g., Padcev)
Enhanced External Counterpulsation (EECP)
Enzyme Replacement Therapy (ERT) for Fabry Disease
Epiduroscopy and Lysis of Epidural Adhesions
Eptinezumab-jjmr (e.g., VYEPTI™)
Eribulin (e.g., HALAVEN)
Erythropoiesis-Stimulating Agents (ESAs)
Esketamine (e.g., SPRAVATO™)
ESWT for Plantar Fasciitis & Other M/S Conditions
Etelcalcetide (e.g., Parsabiv®)(e.g., Calcimimetics)
Evinacumab-dgnb (e.g., Evkeeza)
Ext Insulin Infusion Pumps, CGMs, and Automated Insulin Delivery Systems
Extracorporeal Membrane Oxygenation (ECMO) for Adult Conditions
Extracorporeal Photopheresis
Extracranial Carotid Angioplasty/Stenting
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
Facet Arthroplasty
Facet Joint Denervation
Fam-trastuzumab deruxtecan-nxki (e.g., Enhertu®)
Fecal Calprotectin Testing
Fecal Microbiota Transplantation
Fecal microbiota, live-jslm (e.g., Rebyota)
Focal Treatments for Prostate Cancer
Functional Anesthetic Discography
Functional Magnetic Resonance Imaging of the Brain
Functional Neuromuscular Electrical Stimulation (FNES, FES)
Galectin Measurement
Gastric Electrical Stimulation
Gemtuzumab Ozogamicin (e.g., Mylotarg™)
Gender Affirming Surgery
Gene Test: Chrom Microarray Test_Eval_ Pregancy Loss
Gene Test: Noninvas Prenatal Screen_Fetal Aneuploidies_Cell-Free Fetal DNA
Gene Test: Panel Test Cancers_Genomic Profiling_ Guide Targeted Therapies
Gene Therapies for Hemophilia
Gene Therapies for Thalassemia: Betibeglogene autotemcel (e.g., Zynteglo)
Gene Therapy for Inherited Retinal Dystrophy-Voretigene (e.g., Luxturna)
Genetic & Protein Biomarkers_Dx &Cancer Risk Assessment _Prostate Cancer
Genetic and Lab Testing _Use of 5-Fluorouracil in Pts With Cancer
Genetic Test: Gene Expression Profiling for Cutaneous Melanoma
Genetic Test: Pharmacogenetic Testing for Pain Management
Genetic Test: Allopurinol Sensitivity (HLA-B*5801)
Genetic Test: Alpha and Beta Thalassemia
Genetic Test: Alpha-1 Antitrypsin Deficiency
Genetic Test: Alzheimer’s Disease
Genetic Test: Amyotrophic Lateral Sclerosis
Genetic Test: Analysis of MGMT Promoter Methylation in Malignant Gliomas
Genetic Test: Assays of Gene Ex in Tumor Tissue as a Tech-Prog Pat w Brst C
Genetic Test: Asthma, HLA-DR and HLA-DQ Genotyping
Genetic Test: BCR-ABL1 in CML and ALL
Genetic Test: Beckwith-Wiedemann Syndrome
Genetic Test: Biomarker Testing for Targeted Tx_Breast Cancer
Genetic Test: Biomarker_Targeted Tx and Immunotx_Ovarian Ca
Genetic Test: Biomarker_Targeted Tx and Immunotx_Prostate Ca
Genetic Test: Breast Cancer Risk Assessment (CHEK2, ATM, BARD1)
Genetic Test: Canavan Disease
Genetic Test: Cancer Susceptibility Panels_Measurable Residual Dz
Genetic Test: Carbamazepine HLA-B*1502
Genetic Test: Cardiac Ion Channelopathies
Genetic Test: CHARGE Syndrome
Genetic Test: Cytochrome p450 Genotype-Guided Treatment Strategy
Genetic Test: Diagnosis of Inherited Peripheral Neuropathies
Genetic Test: Dilated Cardiomyopathy
Genetic Test: Duchenne and Becker Muscular Dystrophy
Genetic Test: Epilepsy
Genetic Test: Facioscapulohumeral Muscular Dystrophy
Genetic Test: Familial Cutaneous Malignant Melanoma
Genetic Test: FLT3, NPM1, and CEBPA Mutations in Cytogenetically Normal AML
Genetic Test: FMR1 mutations (including Fragile X Syndrome)
Genetic Test: for PTEN Hamartoma Tumor Syndrome
Genetic Test: Gene Exp Profiling & Protein Marker Analysis Prostate Ca Mgmt
Genetic Test: Gene Expression Testing to Predict CAD (Corus CAD™)
Genetic Test: Gene Expression‒Based Assays for CUP
Genetic Test: Genotyp 9p21 Sgl Nucleotid Polymorphisms-Predict Risc CVD/Ane
Genetic Test: Head & Neck Cancer, EGFR Mutation Analysis
Genetic Test: HER2 Testing
Genetic Test: Hereditary Breast/Ovarian/Hi-Risk Ca (BRCA1, BRCA2, PALB2)
Genetic Test: Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)
Genetic Test: Hereditary Pancreatitis
Genetic Test: Heterozygous Familial Hypercholesterolemia
Genetic Test: HFE Hemochromatosis
Genetic Test: HLA-B*5701 Testing for Abacavir Hypersensitivity Reaction
Genetic Test: Human Leukocyte Antigen (HLA) Testing for Celiac Disease
Genetic Test: JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms
Genetic Test: KIT (c-KIT, CD117)
Genetic Test: Lactase Insufficiency
Genetic Test: Li-Fraumeni Syndrome
Genetic Test: Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic Test: Macular Degeneration
Genetic Test: Mitochondrial Disorders
Genetic Test: Molecular Markers in Fine Needle Aspirates of the Thyroid
Genetic Test: Molecular Test_Pancreatic Cysts_Lesio_Barrett_(PathFinderTG®)
Genetic Test: Molecular_Germline Variants_Ovarian Cancer
Genetic Test: Multicancer Early Detection Testing (eg, Galleri®)
Genetic Test: Multiple Myeloma, Gene Expression Profiling
Genetic Test: Mutation Testing for Limb-Girdle Muscular Dystrophies
Genetic Test: Neurofibromatosis
Genetic Test: Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA
Genetic Test: NOTCH3 Genotyping for Diagnosis of CADASIL
Genetic Test: Pancreatic Cancer
Genetic Test: Preconception or Prenatal Testing as a Carrier Screen
Genetic Test: Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic Test: Preimplantation
Genetic Test: Proteomic Testing for Targeted Therapy in NSCLC
Genetic Test: Prothrombin Thrombophilia and Factor V Leiden and MTHFR
Genetic Test: Rett Syndrome
Genetic Test: Somatic Biomarker Testing (inc Liquid Biopsy)_Metastatic CRC
Genetic Test: Somatic Biomarker Testing for Immune Checkpoint Inhibitor Tx
Genetic Test: Somatic Biomarker Testing_Targeted Tx_NSCLC
Genetic Test: Statin-Induced Myopathy (SLCO1B1)
Genetic Test: Tamoxifen Treatment, Genotype-Guided
Genetic Test: Testing for_Tx w/Thiopurines (TPMT) (NUDT 15)
Genetic Test: Testing NTRK Gene Fusions
Genetic Test: Testing¬_Select Melanoma_Glioma Patients_Targeted Therapy
Genetic Test: Tumor-informed Circulating Tumor DNA_Cancer Management
Genetic Test: UGT1A1 Predict Toxicity Irinotecan (Invader Assay)
Genetic Test: Use of Common Genetic Variants to Predict Risk of Nonfamilial
Genetic Test: Warfarin Dose
Genetic Test: Whole Exome & Whole Genome Sequencing_Dx_Gene Disorders
Genetic Test: X-Linked Opitz G/BBB Syndrome, MID1 Mutation Testing
Genetic Test:Analysis of Human DNA Stool Sample_Colorectal Cancer Screening
Genetic Test:Gene Expression Profiling for Uveal Melanoma
Genetic Test:GEP and ctDNA for Predicting Recurrence Colon Cancer
Genetic Testing: CMA & NGS Panels DD/ID/ASD_Congenital Anomalies
Genetic Testing: Fanconi Anemia
Genetic Testing: Mental Health Conditions
Givosiran (e.g., GIVLAARI®)
Glofitamab-gxbm (e.g., Columvi)
Golimumab (e.g., Simponi Aria®)
Growth Hormone
Gynecomastia Surgery
Hematopoietic Stem Cell Transplant for Misc Solid Tumors in Adults
Hematopoietic Stem Cell Transplant- Trtmnt Germ Cell Tumors
Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia
Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia
Hematopoietic Stem Cell Transplantation for Autoimmune Diseases
Hematopoietic Stem Cell Transplantation for Breast Cancer
Hematopoietic Stem Cell Transplantation for Chronic Myeloid Leukemia
Hematopoietic Stem Cell Transplantation for CLL / SLL
Hematopoietic Stem Cell Transplantation for Epithelial Ovarian Cancer
Hematopoietic Stem Cell Transplantation for Hodgkin Lymphoma
Hematopoietic Stem Cell Transplantation for Multiple Myeloma & POEMS
Hematopoietic Stem Cell Transplantation for Non-Hodgkin Lymphomas
Hematopoietic Stem Cell Transplantation for Primary Amyloidosis
Hematopoietic Stem Cell Transplantation for Solid Tumors of Childhood
Hematopoietic Stem Cell Transplantation for Waldenstrom Macroglobulinemia
Hepsin Biomarker Testing
Hereditary Angioedema, Prophylaxis and Acute Treatment
High-Dose Rate Prostate Brachytherapy
Hip Resurfacing
Hippotherapy
Home Cardiorespiratory Monitoring
Homocysteine Testing
HSCT for Genetic Diseases and Acquired Anemias
HSCT_CNS Embryonal Tumors (eg PNET) and Ependymoma
Hydrogel Implant-SpaceOAR
Hyperbaric Oxygen Pressurization (HBO)
Hyperhidrosis Treatment
IC Balloon Cath Brain Brachytherapy_Malignant Gliomas-Metastasis to Brain
Identification of Microorganisms Using Nucleic Acid Probes
Image Guided Radiation Therapy (IGRT)
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
Immobilized lipase cartridge for enteral feedings (Relizorb™)
Immune Cell Function Assay
Immune Globulin Therapy, Intravenous (IVIG) and Subcutaneous (SCIG)
Implantable Bone Conduction and Bone-Anchored Hearing Aids (BAHA)
Implantable Cardioverter Defibrillator (ICD)
Implantable Infusion Pump
Implantable Sinus Spacers and Stents
IMRT of the Breast and Thorax (Lung, Esophagus, and Mediastinum)
Inclisiran (e.g., Leqvio)
Inebilizumab-cdon (e.g., Uplizna™)
Infertility Services
Infliximab (e.g., Remicade®)
Ingestible pH and Pressure Capsule and Gastric Emptying Breath Testing
Injectable Clostridial Collagenase for Fibroproliferative Disorders
Inotuzumab Ozogamicin (e.g., Besponsa™)
Intensity Modulated Radiation Therapy (IMRT)
Intensity Modulated Radiotherapy: Abdomen and Pelvis
Intensity Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
Intensity Modulated Radiotherapy: Central Nervous System Tumors
Intensity-Modulated Radiotherapy of the Prostate
Interventions for Progressive Scoliosis
Intra-articular Hyaluronan Injections for Osteoarthritis
Intracellular Micronutrient Analysis
Intradialytic Parenteral Nutrition
Intraocular Radiation Therapy for Age-Related Macular Degeneration
Intraoperative Assessment of Tissue
Intraoperative Neurophysiologic Monitoring (IONM)
Intraoperative Radiation Therapy (IORT)
Intravenous Anesthetics (Ketamine or Lidocaine) for the Tx of Chronic Pain
Intravenous Antibiotic Therapy and Associated Diagnostic Lyme Disease
Intravitreal and Punctum Corticosteroid Implants and Ranibizumab
Iobenguane I 131 (e.g., Azedra®)
Ipilimumab (e.g., Yervoy™)
Irinotecan liposome (r.g., ONIVYDE)
Irreversible Electroporation, Nanoknife
Isatuximab-irfc (e.g., Sarclisa®)
Islet Transplantation (Pancreas)
Keratoprosthesis
Laboratory Testing Investigational Services
Laboratory Tests for Organ Transplant Rejection and for Chronic HF
Lanreotide (e.g., Lanreotide injection, Somatuline depot®)
Laparoscopic,Percutaneous,Transcervical Technique _Uterine Fibroid Myolysis
Laser or RF (Ablation, Coblation, Nucleoplasty) Treatment_Back Pain
Laser Therapy for Vaginal Atrophy or Vaginal Relaxation Syndrome
Laser Treatment of Onychomycosis
Laser Treatment of Port Wine Stains and Burn Scars
Leadless Cardiac Pacemakers
Left-Atrial Appendage Closure Devices & Procedure-Stroke Prevention_A-Fib
Lenacapavir (e.g., Sunlenca)
Letermovir e.g., (Prevymis)
Leuprolide acetate (non-Oncologic)
Leuprolide acetate (Oncologic)
Levodopa-carbidopa Intestinal Gel (e.g., Duopa®)
Levoleucovorin Agents (e.g., Fusilev) and (e.g., Khapzory)
Light Therapy for Psoriasis
Light Therapy for Vitiligo
Liposuction for Lipedema and Lymphedema
LITT for Neurological Conditions
Localization Devices for Nonpalpable Breast Lesions
Loncastuximab tesirine-lpyl (e.g., Zynlonta)
Low Level Laser (LLLT) and High Intensity Laser Therapy
Low-Dose Radiotherapy (LDRT) for Non-Oncologic Indications
Lumasiran (e.g., Oxlumo)
Lung Volume Reduction Surgery (LVRS) for Severe Emphysema
Lurbinectedin (e.g., Zepzelca™)
Luspatercept-aamt (e.g., Reblozyl®)
Lutetium Lu 177 Dotatate (e.g., Lutathera®)
Lutetium Lu 177 vipivotide tetraxetan (e.g., Pluvicto)
Macular Translocation
Magnetic Esophageal Sphincter Augmentation to Treat GERD
Magnetic Resonance Imaging (MRI) of the Breast
Magnetic Resonance Spectroscopy
Management of Dry Eye Syndrome
Manipulation under Anesthesia
Margetuximab-cmkb (e.g., MARGENZA)
Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
Meas Exhaled NO & Exh Breath Cond -Dx & Mgmt of Resp Disorders
Meas Lp-PLA2-Assess Cardiovascular Risk
Measurement of Serum Antibodies to IFX, ADA, VDZ, and UST
Medical Management of Obstructive Sleep Apnea Syndrome
Medical Technology Assessment, Non-Covered Services
Melanoma Vaccines
Meniscal Allografts and Other Meniscal Implants
Mepolizumab (e.g., Nucala)
Metabolite Testing Monitor Antimetabolite Ther-Inflam Bowel, Collagen Vasc
Metreleptin (e.g., Myalept)
Microprocessor-Controlled Prosthesis and Orthosis for the Lower Limb
Microwave Tumor Ablation
Minimally Invasive Benign Prostatic Hyperplasia (BPH) Treatments
Minimally Invasive Surgery_ Snoring and Obstructive Sleep Apnea Syndrome
Mirikizumab-mrkz (e.g., Omvoh)
Mirvetuximab soravtansine-gynx (e.g., Elahere)
Mitomycin Gel (e.g., JELMYTO)
Mogamulizumab- kpkc (e.g., Poteligeo)
Molecular Testing in the Management of Pulmonary Conditions
Monoclonal Antibodies for Treatment of Alzheimer Disease
Mosunetuzumab-axgb (e.g. Lunsumio™)
Moxetumomab pasudotox-tdfk* (e.g., LUMOXITI)
MRI Targeted Biopsy and mpMRI of the Prostate
MRI-Guided Focused Ultrasound (MRgFUS) Ablation
Mucopolysaccharidoses Agents
Multibiomarker Test for Monitoring Disease Activity in RA
Multispectral Digital Skin Lesion Analysis
Multitarget PCR Testing for Dx of Bacterial Vaginosis
Myocardial Strain Imaging
Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure
Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Nab-Paclitaxel (e.g., Abraxane™)
Nadofaragene firadenovec-vncg (e.g., Adstiladrin)
Natalizumab (e.g., Tysabri)
Navigated Transcranial Magnetic Stimulation (nTMS)
Naxitamab-gqgk (e.g., Danyelza)
Needle Arthroscopy
Nerve Graft with Radical Prostatectomy
Nesiritide (e.g., Natrecor) for Use in the Outpatient Setting
Neurofeedback (eg Biofeedback Training)
Nirsevimab-alip (e.g., Beyfortus)
Nivolumab and relatlimab-rmbw (e.g., Opdualag)
Non-Contact Ultrasound Treatment for Wounds
Non-Invasive Positive Airway Pressure for COPD
Noninvasive Techniques for the Evaluation & Monitoring of Patients With CLD
Novel Biomarkers in Risk Assessmt & Mgmt of CVD
nterspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Nutrient/Nutritional Panel Testing
Obinutuzumab (e.g., Gazyva®)
Occipital Nerve Stimulation
Ocrelizumab (e.g., Ocrevus)
Octreotide Acetate for Injectable Suspension (e.g., Sandostatin® LAR Depot)
Off-Label Drug Use
Olipudase alfa (e.g., Xenpozyme)
Omalizumab (e.g., Xolair)
Omidubicel as Adjunct Treatment for Hematologic Malignancies
Oncologic Applications of Photodynamic Therapy
Open & Thoracoscop Approaches_ A Fib and A Flutter (Maze and Related Proc)
Ophthalmologic Techniques_Evaluate Posterior Segment for Glaucoma
Opioid Antagonists Under Heavy Sedation or General Anes-Tech Opoid Detoxifi
Optical Coherence Tomography (OCT) of the Anterior Eye Segment
Optical Diagnostic Devices Eval Skin Lesions Susp Malignancy
Orthopedic Applications of Platelet Rich Plasma
Orthopedic Applications of SCT (Inc Allograft and Bone Substitute)
Orthopedic Implants
Orthopedic Postoperative Rehabilitative Devices in the Home Setting
Orthoptic Training for the Treatment of Vision or Learning Disabilities
Outpatient Pulmonary Rehabilitation
Ovarian and Internal Iliac Vein Endovascular Occlusion_Tx Pelvic Congestion
Pain Management, Facet Joint Block (eg. Medial Branch Block)
Panitumumab (e.g., Vectibix™)
Panniculectomy, Abdominoplasty, and Lipectomy
Paraspinal Surface Electromyography (SEMG)- Eval and Monitor Back Pain
Patient-Controlled (Patient-Actuated) End ROM Stretching Devices
PCSK9 Inhibitors (e.g., Evolocumab and Alirocumab)
Pegcetacoplan (e.g., Syfovre)
Pegloticase (e.g., Krystexxa)
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Pembrolizumab
Pemetrexed (e.g., Alimta)
Percutaneous Arteriovenous Fistula (pAVF)
Percutaneous Electrical Nerve Field Stimulation for IBS
Percutaneous Intradiscal Annuloplasty and Intraosseous Nerve Ablation
Percutaneous Kyphoplasty
Percutaneous Tibial Nerve Stimulation
Percutaneous Vertebroplasty and Sacroplasty
Peripheral Nerve Stimulation (PNS, PENS, PNT, PINS)
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
Peroral Endoscopic Myotomy (POEM)
Pertuzumab (e.g., Perjeta®) for Treatment of Malignancies
Pertuzumab, trastuzumab and hyaluronidase-zzxf (e.g., PHESGO™)
PET or PET/CT for Anal Carcinoma
PET or PET/CT for Bone Cancer
PET or PET/CT for Breast Cancer
PET or PET/CT for Cancer Surveillance and Other Oncologic Applications
PET or PET/CT for Cancers of the Thymus, Heart, and Mediastinum
PET or PET/CT for Carcinoma of Unknown Primary (CUP)
PET or PET/CT for Cardiac Applications
PET or PET/CT for Cervical Cancer
PET or PET/CT for Colorectal Cancer
PET or PET/CT for Esophageal or EGJ Cancer
PET or PET/CT for Gastric and Hepatocellular and Biliary Tract Cancers
PET or PET/CT for Head and Neck Malignant Disease
PET or PET/CT for Histiocytic Neoplasms (eg Pulmonary Langerhans)
PET or PET/CT for Hodgkin's Lymphoma
PET or PET/CT for Lymphadenopathy of Unknown Cause
PET or PET/CT for Melanoma
PET or PET/CT for Misc (Non-cardiac, Non-oncologic) Applications
PET or PET/CT for Multiple Myeloma, Plasmacytoma
PET or PET/CT for Neuroendocrine Tumors
PET or PET/CT for Non-Hodgkins Lymphoma and Leukemia
PET or PET/CT for Non-Small Cell Lung Cancer
PET or PET/CT for Ovarian Cancer
PET or PET/CT for Pancreatic Cancer
PET or PET/CT for Penile, Vaginal, and Vulvar Cancers
PET or PET/CT for Pleural Mesothelioma
PET or PET/CT for Primary CNS Cancer
PET or PET/CT for Prostate Cancer, FDG and non-FDG
PET or PET/CT for Small Cell Lung Cancer
PET or PET/CT for Soft Tissue Sarcoma, including GIST
PET or PET/CT for Testicular Germ Cell Cancer
PET or PET/CT for Thyroid Cancer
PET or PET/CT for Urological Cancers
PET or PET/CT for Uterine Cancer
PET or PET/CT, for Alzheimer's Disease, Dementia, or Cognitive Impairment
Photodynamic Therapy for Choroidal Neovascularization
Phrenic Nerve Stimulation for Central Sleep Apnea
Plasma Exchange (Apheresis, Therapeutic)
Plasminogen [e.g., Ryplazim]
Plugs for Anal Fistula Repair
Pneumatic Compression Pumps and Non-Elastic Compression Garments
Polatuzumab vedotin-piiq (e.g., POLIVY)
Polysomnography for Non-Respiratory Sleep Disorders
Positional Magnetic Resonance Imaging (MRI)
Positron Emission Mammography (PEM)
Postsurg Home Use of Limb Comp Devices for Ven Thromboemb Prophylaxis
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
Powered Wheelchairs (PWC) and Standing Frames
Pozelimab-bbfg (e.g., Veopoz)
PPACA rule,NGP_Clinical Trials
Preventive Medical Care (PPACA)
Progenitor Cell Therapy (eg Stem Cell) for the Tx of Damaged Myocardium
Prolotherapy
Prophylactic Oophorectomy to Reduce Ovarian Cancer Risk
Proteomics-based Testing _Ovarian Masses_Cancer (OVA1, Overa, ROMA)
Proton Beam Radiation Therapy
Pt Specific Instrumentation (eg. Cutting Guides) for Joint Arthroplasty
Pulmonary Arterial Hypertension, Infusion and Selected Inhalation therapy
Quantitative Electroencephalography as a Diagnostic Aid for ADHD
Quantitative Sensory Testing
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma
Radium Ra 223 dichloride for Symptomatic Osseous Metastatic Prostate Ca
Ramucirumab (e.g., Cyramza™)
Ravulizumab-cwvz (e.g., Ultomiris)
Recombinant and Autologous PDGF for Wound Healing and Non-Ortho Conditions
Reconstructive Mammaplasty and Contralateral Breast Surgery
Reduction Mammaplasty
Refractive Keratoplasties
Remdesivir (e.g., Veklury)
Remote Electrical Neuromodulation for Migraines
Repository Corticotropin Injection
Reslizumab (e.g., Cinqair®)
Responsive Neurostimulation_Tx_Refractory Focal (Partial) Epilepsy
Retifanlimab-dlwr (e.g., Zynyz)
Retinal Telescreening for Diabetic Retinopathy
RF Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
RFA of the Renal Sympathetic Nerves Tx for Uncontrolled HTN
Rilonacept (e.g., Arcalyst)
Risankizumab (e.g., Skyrizi)
Risk-Reducing Mastectomy
Rituximab (Rituxan)
Rituximab and Biosimilars - Non-Oncologic
Romidepsin (e.g., ISTODAX)
Romosozumab-aqqg (e.g., Evenity®)
Rozanolixizumab-noli (e.g., Rystiggo)
RSV, Immune Prophylaxis with Palivizumab (e.g., Synagis)
Sacituzumab govitecan-hziy (e.g., Trodelvy™)
Sacral Nerve Neuromodulation/Stimulation
Safety Beds
Satralizumab-mwge (e.g., Enspryng™)
Saturation bx for Prostate CA
Scintimammography and Gamma Imaging of the Breast and Axilla
Sebelipase alfa (e.g., Kanuma)
Self-Administered Medication
Sensory Integration Therapy and Auditory Integration Therapy
Serum Biomarker Human Epididymis Protein 4 (HE4)
Serum Biomarker Panel Testing for SLE and other Connective Tissue Diseases
Sexual Dysfunction Svcs & Pharmaceut
Siltuximab (e.g., SYLVANT)
Sirolimus protein-bound particles for injectable suspension (e.g., FYARRO)
Site of Care or Site of Service Review
Small Bowel/Liver and Multivisceral Transplant
Sodium Thiosulfate (e.g., Pedmark)
Spesolimab-sbzo (e.g., Spevigo)
Sphenopalatine Ganglion and Occipital Nerve Block for Headache
Spinal Cord and Dorsal Root Ganglion Stimulation
Stationary Ultrasonic Diathermy Devices
Stem Cell Growth Factor_Romiplostim (e.g., Nplate)
Stem Cell Therapy for Peripheral Arterial Disease
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
Subtalar Arthroereisis for Pes Planus (Flat Feet)
Surgery for Groin Pain in Athletes (Athletic Pubalgia; Sports Hernia)
Surgical Interruption of Pelvic Nerve Pathways-Prim & Second Dysmenorrhea
Surgical Treatment for Lymphedema Secondary to Breast CA
Surgical Treatment of Femoroacetabular Impingement
Surgical Treatment of Pectus Excavatum and Pectus Carinatum
Surgical Treatments for Headache
Sutimlimab-jome (e.g., Enjaymo)
Systems Pathology in Prostate Cancer
TACE to Treat Primary or Metastatic Malignancies
Tafasitamab-cxix (e.g., Monjuvi)
Tagraxofusp-erzs (e.g., Elzonris®)
Talquetamab-tgvs (e.g., Talvey)
Tebentafusp-tebn (e.g., Kimmtrak)
Teclistamab-cqyv (e.g., Tecvayli)
Temporarily Implanted Nitinol Device (iTind) for BPH
Temporomandibular Joint Disorder
Teplizumab-mzwv (e.g. Tzield™)
Teprotumumab-trbw (e.g., TEPEZZA™)
Testing for Drugs of Abuse
Testing for Oral and Esophageal Cancer
Testing Serum Vitamin D Levels
Testosterone Therapy
Tezepelumab-ekko (e.g., Tezspire)
Thermal Ablation of Peripheral Nerves to Treat Pain
Thermography
Tildrakizumab-asmn (e.g., Ilumya)
Tisotumab vedotin-tftv (e.g.,Tivdak™)
Tocilizumab (e.g., Actemra™)
Tofersen (e.g., Qalsody)
Total Artificial Hearts and Implantable Ventricular Assist Devices
Trabectedin (e.g., Yondelis®)
Transanal Endoscopic Microsurgery (TEMS/TAMIS)
Transcatheter Aortic Valve Replacement for Aortic Stenosis
Transcatheter Mitral Valve Repair
Transcatheter Pulmonary Valve Implantation (TPVI)
Transcranial Magnetic Stimulation-Trtmnt of Depression & Other Disorders
Transcutaneous Electrical Nerve Stimulation (TENS)
Transesophageal Endoscopic Therapies for GERD
Transplant, Heart
Transplant, Heart/Lung
Transplant, Isolated Small Bowel
Transplant, Liver
Transplant, Lung and Lobar Lung
Transtympanic Micropressure Applications_Treatment of Meniere's Disease
Trastuzumab(Herceptin)and Trastuzumab/Hyaluronidase-oysk(Herceptin Hylecta)
Travoprost Intracameral implant (iDose® TR)
Treatment for Gaucher Disease
Treatment for SMA
(Zolgensma®)
Treatment of Hereditary Transthyretin-mediated Amyloidosis
Treatment of Tinnitus
Treatment of Urinary & Fecal Incontinence
Treatment of Varicose Veins/Venous Insufficiency
Treatments for DMD
Tremelimumab-actl (e.g. Imjudo)
Triamcinolone Acetonide Extended Release (e.g., Zilretta)
Trilaciclib (e.g., Cosela)
Tumor Antigen, Prostate Specific Antigen (PSA)
Tumor-Treating Fields Therapy for Glioblastoma
Ublituximab-xiiy (e.g., Briumvi)
Ultrafiltration in Decompensated Heart Failure
Ultrasonographic Measurement of Carotid Intima-Medial Thickness
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance
US Accelerated Fracture Healing Device
Ustekinumab (e.g., Stelara)
Uterus Transplantation for Absolute Uterine Factor Infertility
Vacuum Assisted Closure Device/Negative Pressure Wound Treatment
Vagus Nerve Stimulation
Valoctocogene roxaparvovec-rvox (e.g., Roctavian)
Vascular Endothelial Growth Factor Inhibitors for Sickle Cell Retinopathy
Vedolizumab (e.g., Entyvio) for Inflammatory Bowel Disease
Velmanase alfa-tycv (e.g. Lamzede®)
Vertebral Axial Decompression
Vertebral Fracture Assessment with Densitometry (DEXA, DXA)
Vertical Expandable Prosthetic Titanium Rib
Vestibular Function Testing
Virtual Colonoscopy / CT Colonography
Viscocanalostomy and Canaloplasty
Vision services
Voice Prosthesis
Wearable Cardioverter Defibrillators, Wearable Cardiac Vest
Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition
Whole Gland Cryoablation of Prostate Cancer
Wilderness Therapy
Wireless Capsule Endoscopy-Diag Tech- Small Bowel, Esophagus & Colon
Ziv-aflibercept (e.g., Zaltrap)
What You Will See
When you select a policy, you will see its title, category and effective date at the top of the page. A description of the treatment and the
actual policy, which explains what is covered, follow. At the bottom of the page, you will see related CPT codes and references.