Medical Policy

Category:

Abatacept (Orencia)

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Actigraphy

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Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence

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Ado-trastuzumab emtansine (Kadcyla®)

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Adoptive Immunotherapy

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Agalsidase beta (Fabrazyme)

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Alemtuzumab (Lemtrada™)

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Alglucosidase alfa (Lumizyme)

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Allergy Immunotherapy

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Allergy Skin Testing

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Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

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Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias

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Alpha1-Proteinase Inhibitor Infusions

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Ambulance Services: Air and Water Transportation

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Ambulance Services: Ground Transportation

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Ambulatory Blood Pressure Monitoring (ABPM)

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Ankle-Foot/Knee-Ankle-Foot Orthosis

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Anser ADA and Anser IFX

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Aqueous Shunts and Stents for Glaucoma

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Arthrocentesis or Needling of Bursa

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Artificial Intervertebral Disc Replacement

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Assays of Genetic Expression in Tumor tissue as a Technique to Determine Prognosis in patients with Breast Cancer

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Assisted Reproductive Technology

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Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

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Autologous Cellular Immunotherapy for Prostate Cancer

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Autologous Chondrocyte Implantation

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Autonomic Nervous System Function Testing

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Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents

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BCR-ABL Negative Myeloproliferative Neoplasm Testing

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BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia

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Beds- Accessories and Related Items

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Belatacept (Nulojix)

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Belimumab (Benlysta)

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Bendamustine (Treanda®, Bendeka®, Belrapzo™)

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Bevacizumab (Avastin, Mvasi)

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Biofeedback

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Biomarkers in Risk Assessment and Management of Cardiovascular Disease

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Bone Growth Stimulation

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Bone Mineral Density Studies

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bortezomib (Velcade®)

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Braces and Supports

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BRCA Analysis

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Brexanolone (Zulresso)

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Burosumab (Crysvita)

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Carboplatin (Paraplatin)

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Cardiac Ablation Procedures

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Cardiac Monitors

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Cardiac Rehabilitation Programs, Phase II Outpatient

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Carfilzomib (Kyprolis)

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Carrier Testing for Genetic Diseases

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Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS)

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Cerliponase Alfa (Brineura)

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Charcot-Marie-Tooth Neuropathy Testing Panel

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Chemodenervation with Botulinum Toxin)

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Chromosomal Microarray Testing for Developmental Disorders

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Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss

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Chronic Pain Programs

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Chronic Wound Management

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Cleft Palate Reconstruction

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Clinical Trials

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Cochlear Implantation

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Cognitive Rehabilitation

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Continuous Glucose Monitors (CGM)

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Contraceptive Management

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Copanlisib (Aliqopa)

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Corneal Collagen Cross-Linking

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Corneal Surgery to Correct Refractive Errors and Phototherapeutic Keratectomy

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Corneal Topography – Computer-Assisted Corneal Topography – Photokeratoscopy

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Coronary Revascularization

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Cosmetic Surgery vs. Reconstructive Surgery

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Cranial Electrical Stimulators

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Cranial Orthosis for Plagiocephaly

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Cryosurgical Ablation and Radiofrequency Ablation of Renal Tumors

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CT (Virtual) Colonoscopy

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CTA Coronary Arteries and Fractional Flow Reserve CT

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Daunorubicin and Cytarabine Liposomal (Vyxeos)

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Decompression Therapy

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Devices Used for the Treatment of Sleep Apnea in Adults

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Diabetic Services and Supplies

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Diagnosis and Management of Idiopathic Environmental Intolerance – Clinical Ecology

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Diagnosis and Treatment of Male Sexual Dysfunction

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Diagnosis and Treatment of Obstructive Sleep Apnea for Adults

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Diagnosis and Treatment of Obstructive Sleep Apnea for Adults

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Diagnosis and Treatment of Obstructive Sleep Apnea in Children

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Diagnosis and Treatment of Sacroiliac Joint Pain

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Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy

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Discography

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Docetaxel (Taxotere)

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Drug Indications

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Drug Indications

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Drug Testing in Pain Management and Substance Abuse Treatment

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Dynamic Posturography

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Dynamic Splinting Devices

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Eculizumab (Soliris)

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Edaravone (Radicava)

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EGFR Testing for Non-Small Cell Lung Cancer TKI Response

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Electric Breast Pumps

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Electrical Nerve Stimulation

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Electrical Stimulation Devices for the Treatment of Arthritis

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Electroencephalogram (EEG) Technologies

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Electroretinography

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Elosulfase alfa (Vimizim)

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Emapalumab-lzsg (Gamifant)

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Esketamine (Spravato)

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Esophageal pH Monitoring

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Eustachian Tube Balloon Dilation

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Exondys 51 (eteplirsen)

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Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies

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External Counterpulsation (ECP)

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External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing

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Extracorporeal Photopheresis

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Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions

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Factor II/Prothrombin Testing for Thrombophilia

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Factor V Leiden Testing for Thrombophilia

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Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

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Fecal Microbiota Transplantation

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Feeding Disorder Program – Partial Hospital Program (PHP) and Intensive Outpatient Program (IOP)

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FibroTest/FibroSURE

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Foot Orthotics for Conditions Other Than Diabetes

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Fulvestrant (Faslodex)

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Functional Neuromuscular Electrical Stimulation

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Galsulfase (Naglazyme)

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Gastric Electrical Stimulation, Gastric Pacing

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Gemcitabine HCl (Gemzar®)

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Gender Reassignment Surgery

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Gene Expression Profiling Tests for Prostate Cancer

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Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

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Genetic Cancer Susceptibility Panels Using Next Generation Sequencing

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Genetic Testing

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Genetic Testing for Alzheimer Disease

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Genetic Testing for Dilated Cardiomyopathy

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Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia

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Genetic Testing for Inherited Thrombophilia

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Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

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Genetic Testing for Mental Health

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Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

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Genetic Testing for PTEN Hamartoma Tumor Syndrome

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Genetic Testing for Tamoxifen Treatment

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Golimumab (Simponi Aria)

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Gonadotropin Releasing Hormones (GnRHs) Analogs

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Granulocyte Colony-Stimulating Factors

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Heart Transplantation Adult and Pediatric

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Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

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Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

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Hematopoietic Cell Transplantation for Autoimmune Diseases

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Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

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Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

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Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma

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Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer

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Hematopoietic Cell Transplantation for Hodgkin Lymphoma

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Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

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

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Hematopoietic Cell Transplantation for Primary Amyloidosis

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Hematopoietic Cell Transplantation for Solid Tumors of Childhood

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Hematopoietic Cell Transplantation for Treatment of Germ-Cell Tumors

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Hematopoietic Stem-Cell Transplantation for Multiple Myeloma and POEMS Syndrome

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Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

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Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

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Hereditary Hemochromatosis Testing

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High Frequency Chest Wall Oscillation Devices

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High Resolution Anoscopy (HRA)

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Hip Arthroscopies

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Home Cervical Traction Therapy

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Home Health- Extended Hours

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Home Pulse Oximetry Device

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Home Uterine Activity Monitor

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Homocysteine Testing in Cardiovascular Disease

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Hospice

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Human Leukocyte Antigen (HLA) Testing for Celiac Disease

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Hyperbaric Oxygen Therapy

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Identification of Microorganisms Using Nucleic Acid Probes

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Idursulfase (Elaprase)

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Immune Globulin Therapy

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Immune Prophylaxis for Respiratory Syncytial Virus (RSV)

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Implantable Automatic Cardioverter-Defibrillator

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In Vitro Allergy Testing

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Infliximab

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Injectable Collagenase Clostridium Histolyticum

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Inotuzumab Ozogamicin (Besponsa)

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Insulin Pump, Sensor Augmented Pump (Artificial Pancreas Device System) and Continuous Glucose Monitoring Devices

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Interferential Stimulator

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Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment

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Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

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Intra-Arterial/Intravenous Therapeutic Procedures

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Intra-Articular Hyaluronan Injections for Osteoarthritis of the Knee

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Intracellular Micronutrient Testing Panel

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Intradiscal Electrothermal Annuloplasty (IDEA) or Intradiscal Electrothermal Therapy (IDET)

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Intraocular Lens

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Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)

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Intraperitoneal Chemotherapy

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Ipilimumab (Yervoy)

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Irinotecan Liposomal (Onivyde)

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Islet Transplantation

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Knee Orthosis

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Kyphoplasty

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Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease

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Liver Transplant

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Lumbar Spine/Sacroiliac Fusion Surgery and Axial-Lumbosacral Interbody Fusion

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Lung and Lobar Lung Transplant

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Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (LINX®)

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Magnetic Resonance Imaging (MRI) of the Breast

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Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)

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Magnetoencephalograpy

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Manipulation Services

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Manipulation Under Anesthesia (MUA)

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Mastectomy and Reconstructive Surgery

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Measurement of Exhaled Nitric Oxide

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Medication Assisted Treatment (MAT)

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Meniscal Allograft Transplantation

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Microprocessor-Controlled Prostheses for Lower Limb

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Moderate Penetrance Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk

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Mogamulizumab-kpkc (Poteligeo)

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Mohs Micrographic Surgery (MMS)

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Monitored Anesthesia Care

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Monoclonal Antibodies for the Treatment of Eosinophilic Conditions

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Moxetumomab Pasudotox (Lumoxiti)

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Myoelectric Prosthetic Components for the Upper Limb

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Natalizumab (Tysabri®)

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Nebulizers

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Negative Pressure Wound Therapy (NPWT) Pumps/Vacuum Assisted Closure (VAC) of Chronic Wounds

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Nerve Conduction Velocity Studies (NVC) and Electromyography (EMG)

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Non-invasive Peripheral Arterial Studies

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Non-Invasive Prenatal Testing

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Non-Powered Negative Pressure Wound Therapy System

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

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Nusinersen (Spinraza)

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Obesity

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Occupational Therapy (OT)

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Ocrelizumab (Ocrevus)

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Ocular Photodynamic Therapy (PDT)

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Omalizumab (Xolair)

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Onasemnogene abeparvovec (Zolgensma)

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Oncologic Applications of Positron Emission Tomography Scanning

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Oncologic Indications for Histone deacetylase (HDAC) inhibitors

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Oncotype DX for Colorectal Cancer Recurrence Risk

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OralCDx Brush Biopsy

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Orthopedic Applications of Stem-Cell Therapy

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Osseointegrated Dental Implants

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Ostomy Supplies

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Ovarian and Internal Iliac Vein Embolization for Pelvic Congestion Syndrome

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Pain Management of Peripheral Nerves by Injection

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Palonosetron (Aloxi)

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Pancreas Transplantation

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Pap Smears with Medical Conditions

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Partial and Total Hip Resurfacing Arthroplasty

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Pegaspargase (Oncaspar®) and Asparaginase Erwinia Chrysanthemi (Erwinaze)

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Pegloticase (Krystexxa™)

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Pemetrexed (Alimta)

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Percutaneous Discectomy

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Percutaneous Vertebroplasty

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Pertuzumab (Perjeta)

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Pharmacogenetic Testing for Pain Management

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Pharmacologic Treatment of Pulmonary Arterial Hypertension

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Pheresis Therapy

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Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCI [ALA] or Metvixia® (Methyl Aminolevulinate)

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Photography

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Physical Therapy (PT)

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Pneumatic Compression Devices

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Polysomnography (PSG) for Non-Respiratory Sleep Disorders

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Portable External Infusion Pump

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Posterior Tibial Nerve Stimulation

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Powered Exoskeletal Robotic Systems

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Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies

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Proton Beam Radiation Therapy – FM HomeBuilders Consortium only

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Proton Beam Therapy 2019

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Radiation Treatment with Lutathera

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Radiofrequency Ablation (RFA) and Cryosurgery of Primary or Metastatic Liver Tumors

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Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

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Radiofrequency Facet Denervation

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Ramucirumab (Cyramza®)

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Ravulizumab-cwvz (Ultomiris)

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Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions

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Removal of Benign or Premalignant Skin Lesions

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Removal of Benign or Premalignant Skin Lesions

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Respiratory Assist Devices

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Rituximab (Rituxan, Truxima) and Rituximab and Hyaluronidase Human (Rituxan Hycela)

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Romosozumab-aqqg (Evenity)

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Sacral Nerve Neuromodulation/Stimulation

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Saliva Hormone Testing

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Sebelipase alfa (Kanuma)

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Selective Internal Radiation Therapy (SIRT)/Radioembolization

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Single Photon Emission Computed Tomography (SPECT)

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Solitary Pancreas Transplantation

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Speech Generating Devices

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Speech Therapy

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Spinal Cord and Dorsal Root Ganglion Stimulation

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Subtalar Arthroereisis

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Surgical Treatment of Varicose Veins

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Synribo (omacetaxine mepesuccinate)

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Tagraxofusp-erzs (Elzonris)

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Telehealth

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Telehome Telemonitoring for Congestive Heart Failure and/or Chronic Obstructive Pulmonary Disease

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Temporomandibular Joint (TMJ) Dysfunction

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Thermal Capsulorrhaphy as a Treatment of Joint Instability

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Thermography (Thermogram)

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tildrakizumab-asmn (Ilumya)

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Tocilizumab (Actemra)

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Total Ankle Replacement

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TPMT Testing for Thiopurine Drug Response

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Transcatheter Aortic Valve Replacement (TAVR)

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Transcatheter Arterial Chemoembolization

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Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

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Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

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Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease

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Trastuzumab (Herceptin), Trastuzumab Biosimilars, and Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)

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Treatment of Abnormal Uterine Bleeding and Fibroids

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Treatment of Abnormal Uterine Bleeding and Fibroids 2019

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Treatment of Gaucher Disease

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Treatment of Hereditary Amyloidosis

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Treatment of Hereditary Angioedema (HAE)

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Treatment of Hyperhidrosis

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Treatment of the Prostate

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Triptorelin (Triptodur)

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Tumor Markers

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Tumor Markers

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Tumor Treatment Fields (TTF)

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Ultrasound Osteogenesis Stimulator

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Ultraviolet Light Therapies

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Urological Supplies

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UroVysion FISH for Bladder Cancer

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Ustekinumab (Stelara®)

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Vedolizumab (Entyvio®)

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Vestronidase Alfa (Mepsevii)

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Vitamin D Assay

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Voretigene Neparvovec-rzyl (Luxturna)

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Wearable Cardioverter-Defibrillator

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Wheelchairs (WC) and Options/Accessories

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Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

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

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Ziv-aflibercept (Zaltrap)

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