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#
3D Rendering on CT/MRI/US
A
Ankle Arthroplasty
Artificial Disc Replacement
Autologous Chondrocyte Implantation and MACI
B
Back Pain Procedures - Epidural Injections
Back Pain Procedures - Radiofrequency Ablation, Facet Joint and Other Injections
Back Pain - Sacroiliac Joint and Coccydynia Treatments
Blepharoplasty, Blepharoptosis, and Brow Lift
Bone Growth Stimulators
C
Cartilage Transfer Procedures: OATS and Mosaicplasty
Cochlear Implants Bone Anchored Hearing Aids
Corneal Treatments and Specialized Contact Lenses
E
Emergency Air Ambulance medical policy effective 11/1/24
G
Gender Dysphoria Treatment
Glaucoma Surgical Treatments
H
Hip Replacement Surgery
Hyperbaric Oxygen Therapy
I
Infertility and Recurrent Pregnancy Loss Testing and Treatment
K
Knee Replacement Surgery
M
Meniscal Allograft Transplantation
MRI (Magnetic Resonance Imaging), MRE (Magnetic Resonance Enterography), and MRCP (Magnetic Resonance Cholangiopancreatography) of the Abdomen
MRI (Magnetic Resonance Imaging) of the Breast
MRI (Magnetic Resonance Imaging) Cardiac
MRI (Magnetic Resonance Imaging) of the Chest
MRI (Magnetic Resonance Imaging) of the Head/Brain
MRI (Magnetic Resonance Imaging) of the Neck, Face, Orbit
MRI (Magnetic Resonance Imaging) of the Pelvis
MRI (Magnetic Resonance Imaging) of the Spine (Cervical, Thoracic, Lumbar)
MRI (Magnetic Resonance Imaging) of Upper and Lower Extremities
Multiplex Polymerase Chain Reaction (mPCR) or Nucleic acid Pathogen Testing for Infectious Disease
N
Negative Pressure Wound Therapy
Neuropsychological Testing
New-to-Market Medication List
New-to-Market Medication Policy
Non-Covered Services and Procedures
P
Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment
PET Scan (Positron Emission Tomography)
Physical and Occupational Therapy Services
Pneumatic Compression Devices
R
Reduction Mammoplasty for Symptomatic Macromastia
S
Septoplasty and Rhinoplasty
Shoulder Replacement Surgery
Skin and Soft Tissue Substitutes
Sleep Disorder Testing
Sleep Disorder Treatment (Oral Appliances and PAP devices)
Spinal Cord and Peripheral Nerve Stimulators
Spinal Manipulation and Chiropractic Services
T
Tumor Treating Fields (Alternating Electric Field Therapy)
U
Urine Drug/Alcohol Screening and Testing
V
Varicose Vein Treatments
W
Whole Exome Sequencing (WES) and Whole Genome Sequencing (WGS)
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