| A |
|
|
|
| Ablative Treatment for Malignant Breast Tumor - (0540) |
PDF |
238kB |
03/15/2024 |
| Abortion - (A006) |
PDF |
175kB |
03/15/2024 |
| Acupuncture - (CPG024) |
PDF |
628kB |
04/15/2024 |
| Adjustable Continence Therapy - (0573) |
PDF |
284kB |
09/15/2024 |
| Airway Clearance Devices in the Ambulatory Setting - (0069) |
PDF |
311kB |
11/12/2023 |
| Airway Clearance Devices in the Ambulatory Setting - (0069) ---- future effective policy |
PDF |
294kB |
01/15/2025 |
| Allergy Testing and Non-Pharmacologic Treatment - (0070) |
PDF |
358kB |
05/15/2024 |
| Ambulance Services - (0555) |
PDF |
207kB |
09/15/2024 |
| Ambulatory External and Implantable Electrocardiographic Monitoring - (0547) |
PDF |
463kB |
11/15/2024 |
| American Society of Addiction Medicine (ASAM) Guideline |
Online Resource |
|
|
| Anesthesia and Facility Services for Dental Treatment - (0415) |
PDF |
281kB |
08/15/2024 |
| Anesthesia Services for Interventional Pain Management Procedures in an Adult - (0551) |
PDF |
436kB |
02/15/2024 |
| Angioplasty (Extracranial, Intracranial) and Intracranial Aneurysm Repair - (0545) |
PDF |
|
|
| Atrial Fibrillation: Nonpharmacological Treatments - (0469) |
PDF |
561kB |
10/15/2024 |
| Attention-Deficit/Hyperactivity Disorder (ADHD): Assessment and Treatment - (0231) |
PDF |
383kB |
04/01/2024 |
| Authorized Generics - (A008) |
PDF |
189kB |
11/15/2024 |
| Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447) |
PDF |
503kB |
04/01/2024 |
| Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447) ---- future effective policy |
PDF |
516kB |
01/15/2025 |
| Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP]) - (0507) |
PDF |
489kB |
10/15/2024 |
| Autonomic Nerve Function Testing - (0506) |
PDF |
293kB |
02/15/2024 |
| Axial/Spinal Decompression Therapy/Mechanical Traction (Provided in a Clinic Setting) - (CPG275) |
PDF |
405kB |
04/15/2024 |
| B |
|
|
|
| Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation - (0480) |
PDF |
374kB |
04/15/2024 |
| Bariatric Surgery and Procedures - (0051) |
PDF |
1299kB |
07/15/2023 |
| Bariatric Surgery and Procedures - (0051) ---- future effective policy |
PDF |
1260kB |
01/15/2025 |
| Behavioral Health Coaching and Peer Support Services - (A015) |
PDF |
188kB |
04/15/2023 |
| Benign Prostatic Hyperplasia (BPH) Surgical Treatments - (0159) |
PDF |
309kB |
11/01/2024 |
| Biofeedback - (CPG294) |
PDF |
675kB |
11/15/2024 |
| Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift - (0045) |
PDF |
291kB |
04/15/2024 |
| Bone Graft Substitutes - (0118) |
PDF |
296kB |
11/01/2024 |
| Bone Growth Stimulators: Electrical (Invasive), Ultrasound - (0084) |
PDF |
257kB |
11/01/2024 |
| Bone Mineral Density Measurement - (0300) |
PDF |
409kB |
04/15/2024 |
| Brachytherapy |
Online Resource |
|
|
| Breast Implant Removal - (0048) |
PDF |
291kB |
04/01/2024 |
| Breast Reconstruction Following Mastectomy or Lumpectomy - (0178) |
PDF |
622kB |
09/15/2024 |
| Breast Reduction - (0152) |
PDF |
270kB |
08/15/2024 |
| C |
|
|
|
| Capsule Endoscopy |
Online Resource |
|
|
| Cardiac Catheterization |
Online Resource |
|
|
| Cardiac Electrophysiological (EP) Studies - (0532) |
PDF |
352kB |
10/15/2024 |
| Cardiac Nuclear Imaging |
Online Resource |
|
|
| Cardiac Omnibus Codes - (0574) |
PDF |
575kB |
11/01/2024 |
| Cardiac Rehabilitation (Phase II Outpatient) - (0073) |
PDF |
403kB |
06/15/2024 |
| Cardiac Resynchronization Therapy (CRT) and Advanced Cardiac Pacing Technologies - (0174) |
PDF |
589kB |
09/01/2024 |
| Cardiac Stress Echocardiography |
Online Resource |
|
|
| Cardioverter-Defibrillator Devices - (0431) |
PDF |
677kB |
08/15/2024 |
| Cardioverter-Defibrillator Devices - (0431) ---- future effective policy |
PDF |
671kB |
12/15/2024 |
| Carotid Intima-Media Thickness Measurement - (0475) |
PDF |
254kB |
05/15/2024 |
| Category III Current Procedural Terminology (CPT®) Codes - (0558) |
PDF |
269kB |
08/15/2024 |
| Cell-Based Therapy for Cardiac and Peripheral Arterial Disease - (0287) |
PDF |
313kB |
05/15/2024 |
| Cervical Cancer Screening Visualization Technologies - (0127) |
PDF |
177kB |
10/15/2024 |
| Cervical Fusion - (0527) |
PDF |
|
|
| Cervical Surgeries and Procedures ---- Replaces CPs 0040, 0104, 0393, 0448, 0527 |
Online Resource |
|
11/01/2024 |
| Chiropractic Care - (CPG278) |
PDF |
515kB |
04/15/2024 |
| Cigna Healthcare Medicare Advantage Coverage Policy Development and Application - (A018) |
PDF |
168kB |
08/01/2024 |
| Clinical Trials – (A003) |
PDF |
197kB |
12/15/2023 |
| Cochlear and Auditory Brainstem Implants - (0190) |
PDF |
510kB |
11/15/2024 |
| Cognitive Rehabilitation - (CPG270) |
PDF |
522kB |
07/15/2024 |
| Colorectal Cancer Screening and Surveillance - (0148) |
PDF |
527kB |
11/15/2023 |
| Comparative Genomic Hybridization (CGH)/Chromosomal Microarray Analysis (CMA) for Selected Hereditary Conditions - (0493) |
PDF |
|
|
| Complex Lymphedema Therapy (Complete Decongestive Therapy) - (CPG157) |
PDF |
463kB |
05/15/2024 |
| Compression Devices - (0354) |
PDF |
407kB |
11/15/2024 |
| Computed Tomography (CT) |
Online Resource |
|
|
| Computed Tomography Angiography (CTA) |
Online Resource |
|
|
| Computed Tomography for Lung Cancer Screening |
Online Resource |
|
|
| Continuity of Care Service Requests - (UM-41) |
PDF |
3694kB |
04/23/2024 |
| Continuous Passive Motion (CPM) Devices - (0198) |
PDF |
263kB |
08/15/2024 |
| Corneal Remodeling for Refractive Errors - (0141) |
PDF |
412kB |
10/15/2023 |
| COVID-19: In Vitro Diagnostic Testing - (0557). |
PDF |
396kB |
06/15/2024 |
| Custodial and Non-Skilled Services - (A012) |
PDF |
196kB |
10/15/2023 |
| D |
|
|
|
| Deep Brain, Motor Cortex and Responsive Cortical Stimulation - (0184) |
PDF |
555kB |
04/01/2024 |
| Diabetes Equipment and Supplies - (0106) |
PDF |
671kB |
10/18/2024 |
| Diabetes Equipment and Supplies - (0106) ---- future effective policy |
PDF |
689kB |
01/15/2025 |
| Diagnostic Cardiac Catheterization |
Online Resource |
|
|
| Diagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy - (0554) |
PDF |
514kB |
06/16/2024 |
| Diaphragmatic/Phrenic Nerve Stimulation - (0391) |
PDF |
429kB |
07/15/2024 |
| Discography - (0393) |
PDF |
|
|
| Donor Lymphocyte Infusion and Hematopoietic Progenitor Cell (HPC) Boost - (0261) |
PDF |
241kB |
05/15/2024 |
| Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery - (0481) |
PDF |
306kB |
04/15/2024 |
| Drug Testing - (0513) |
PDF |
254kB |
01/15/2024 |
| Duplex Scan to Evaluate for Carotid Artery Stenosis - (0542) |
PDF |
385kB |
06/15/2024 |
| E |
|
|
|
| Electrical Stimulation Therapy and Devices in a Home Setting - (0160) |
PDF |
870kB |
12/03/2023 |
| Electrical Stimulation Therapy and Devices in a Home Setting - (0160) ---- future effective policy |
PDF |
516kB |
01/15/2025 |
| Electric Stimulation for Pain, Swelling and Function in a Clinic Setting - (CPG272) |
PDF |
968kB |
08/15/2024 |
| Electrodiagnostic Testing (EMG/NCV) - (CPG129) |
PDF |
928kB |
09/15/2024 |
| Electroencephalography - (0521) |
PDF |
251kB |
01/15/2024 |
| Emergency Room Services - (A005) |
PDF |
132kB |
10/01/2023 |
| Endometrial Ablation - (0013) |
PDF |
265kB |
02/15/2024 |
| Epidural Adhesiolysis - (CMM 207) |
Onine Resource |
|
|
| Epidural Steroid Injections - (CMM 200) |
Online Resource |
|
|
| Esophagogastroduodenoscopy (EGD) |
Online Resource |
|
|
| Evernorth Coverage Policy - Complementary and Alternative Medicine - (EN0086) |
PDF |
694kB |
11/15/2024 |
| Evernorth Coverage Policy - Intensive Behavioral Interventions - (EN0499) |
PDF |
349kB |
11/15/2024 |
| Evernorth Coverage Policy - Neuropsychological Testing - (EN0258) |
PDF |
508kB |
11/10/2024 |
| Evernorth Coverage Policy - Transcranial Magnetic Stimulation - (EN0383) |
PDF |
546kB |
11/15/2024 |
| Extracorporeal Photopheresis - (0320) |
PDF |
213kB |
08/15/2024 |
| Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds - (0004) |
PDF |
550kB |
11/15/2023 |
| F |
|
|
|
| Facet Joint Injections / Medial Branch Blocks - (CMM 201) |
Online Resource |
|
|
| Fetal Surgery - (0175) |
PDF |
257kB |
07/15/2024 |
| Flow Cytometry - (0538) |
PDF |
367kB |
09/15/2024 |
| G |
|
|
|
| Gait Analysis - (0315) |
PDF |
251kB |
08/17/2024 |
| Gastric Pacing/Gastric Electrical Stimulation (GES) - (0103) |
PDF |
294kB |
11/15/2023 |
| Gastrointestinal Endoscopic Procedure Esophagogastroduodenoscopy (EGD) |
Online Resource |
|
|
| Gender Dysphoria Treatment - (0266) |
PDF |
345kB |
10/15/2024 |
| Gender Dysphoria Treatment - State Guidelines |
PDF |
184kB |
01/01/2024 |
| Genetic Testing for Hereditary and Multifactorial Conditions - (0052) |
PDF |
419kB |
11/01/2024 |
| Genetic Testing for Hereditary Cancer Susceptibility Syndromes - (0518) |
PDF |
|
|
| Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias - (0517) |
PDF |
|
|
| Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514) |
PDF |
697kB |
11/01/2024 |
| Genetic Testing Recommendation Form ---- retired |
Online Resource |
|
11/01/2024 |
| Glaucoma Surgical Procedures - (0035) |
PDF |
426kB |
10/15/2024 |
| Gynecomastia Surgery - (0195) |
PDF |
222kB |
08/15/2024 |
| H |
|
|
|
| Headache, Occipital, and/or Trigeminal Neuralgia Treatment - (0063) |
PDF |
462kB |
11/01/2024 |
| Head and Neck Ultrasound - (0549) |
PDF |
399kB |
08/15/2024 |
| Hearing Aids - (0093) |
PDF |
447kB |
05/15/2024 |
| Heart, Lung, and Heart-Lung Transplantation - (0129) |
PDF |
323kB |
09/15/2024 |
| Helicobacter Pylori Serology Testing –(0308) |
PDF |
183kB |
05/15/2024 |
| High Intensity Focused Ultrasound (HIFU) - (0274) |
PDF |
474kB |
01/15/2024 |
| Hip Replacement/Arthroplasty - (CMM 313) |
Online Resource |
|
|
| Hip Surgery - Arthroscopic and Open Procedures - (CMM 314) |
Online Resource |
|
|
| Home Traction Devices - Cervical and Lumbar - (CPG265) |
PDF |
332kB |
04/15/2024 |
| Home Ventilators - (0546) |
PDF |
241kB |
06/15/2024 |
| Hospice Care - (0462) |
PDF |
260kB |
02/15/2024 |
| Hospital Beds and Pressure Reducing Support Surfaces - (0042) |
PDF |
353kB |
11/15/2024 |
| Hyperbaric and Topical Oxygen Therapies - (0053) |
PDF |
498kB |
05/15/2024 |
| Hyperthermia |
Online Resource |
|
|
| I |
|
|
|
| Image-Guided Radiation Therapy (IGRT) |
Online Resource |
|
|
| Implantable Intrathecal Drug Delivery Systems - (CMM 210) |
Online Resource |
|
|
| Infertility Services - (0089) |
PDF |
685kB |
10/15/2024 |
| Inflammatory Bowel Disease - Testing for the Diagnosis and Management - (0121) |
PDF |
539kB |
11/01/2024 |
| Inhaled Nitric Oxide (INO) - (0453) |
PDF |
523kB |
07/15/2024 |
| Injectable Fillers - (0511) |
PDF |
254kB |
05/15/2024 |
| Interspinous Process Spacer Devices - (0448) |
PDF |
|
|
| Intervertebral Disc (IVD) Prostheses - (0104) |
PDF |
|
|
| Intestinal and Multivisceral Transplantation - (0288) |
PDF |
249kB |
12/15/2023 |
| Intraocular Lens Implant - (0125) |
PDF |
274kB |
09/15/2024 |
| Intraoperative Monitoring - (0509) |
PDF |
644kB |
09/15/2024 |
| K |
|
|
|
| Kidney Transplantation, Pancreas-Kidney Transplantation, and Pancreas Transplantation Alone - (0146) |
PDF |
284kB |
10/15/2024 |
| Knee Replacement/Arthroplasty - (CMM 311) |
Online Resource |
|
|
| Knee Surgery: Arthroscopic and Open Procedures - (CMM 312) |
Online Resource |
|
|
| L |
|
|
|
| Laboratory Testing for Transplantation Rejection - (0465) |
PDF |
374kB |
11/01/2024 |
| Lack of Information (LOI) Pre-Service - (UM-49) |
PDF |
2233kB |
02/27/2024 |
| Lack of Information (LOI) Retrospective Review - (UM-47) |
PDF |
2086kB |
08/13/2024 |
| Laser Interstitial Thermal Therapy - (0528) |
PDF |
328kB |
08/15/2024 |
| Liver and Liver-Kidney Transplantation - (0355) |
PDF |
492kB |
05/15/2024 |
| Low-Level Laser and High-Power Laser Therapy - (CPG030) |
PDF |
628kB |
04/15/2024 |
| Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, including Sacroiliac Fusion - (0303) |
PDF |
|
|
| Lumbar Surgeries and Procedures ---- Replaces CPs 0040, 0104, 0303, 0393, 0448 |
Online Resource |
|
11/01/2024 |
| Lyme Disease Treatment - Antibiotic Treatment - (0400) |
PDF |
530kB |
07/15/2024 |
| Lymphedema and Lipedema Surgical Treatments - (0531) |
PDF |
603kB |
11/15/2024 |
| M |
|
|
|
| Magnetic Resonance Angiography (MRA) |
Online Resource |
|
|
| Magnetic Resonance Imaging (MRI) |
Online Resource |
|
|
| Magnetic Resonance Imaging (MRI), Breast |
Online Resource |
|
|
| Magnetic Resonance Imaging (MRI), Cardiac |
Online Resource |
|
|
| Magnetic Resonance Spectroscopy (MRS) |
Online Resource |
|
|
| Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403) |
PDF |
463kB |
08/15/2024 |
| Mammary Ductoscopy, Aspiration and Lavage - (0057) |
PDF |
315kB |
01/15/2024 |
| Manipulation Under Anesthesia - (0276) |
PDF |
289kB |
10/15/2024 |
| Metatarsophalangeal Joint Replacement - (0446) |
PDF |
281kB |
09/15/2024 |
| Midwife, Home Birth and Non-Clinical Maternal Services - (A002) |
PDF |
166kB |
06/15/2024 |
| Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) Procedures - (0019) |
PDF |
789kB |
08/15/2024 |
| Miscellaneous Musculoskeletal Procedures - (0515) |
PDF |
584kB |
07/15/2024 |
| Molecular and Proteomic Diagnostic Testing for Hematology and Oncology Indications - (0520) |
PDF |
536kB |
11/01/2024 |
| Molecular Laboratory Testing ---- Replaces CPs 0493, 0517, 0518, 0519 |
Online Resource |
|
11/01/2024 |
| Mucosal Integrity Testing - (0577) |
PDF |
192kB |
10/15/2024 |
| N |
|
|
|
| Negative Pressure Wound Therapy/Vacuum Assisted Closure (VAC) for Nonhealing Wounds - (0064) |
PDF |
394kB |
05/15/2024 |
| Network Adequacy Provision (NAP) - (UM-20) |
PDF |
2278kB |
09/10/2024 |
| Neutron Beam Radiation Therapy for Cancer Treatment |
Online Resource |
|
|
| Non-Participating Laboratory Services - (A001) |
PDF |
132kB |
06/15/2024 |
| Nucleic Acid Pathogen Testing - (0530) |
PDF |
664kB |
11/10/2024 |
| Nutritional Support - (0136) |
PDF |
262kB |
11/15/2024 |
| O |
|
|
|
| Occupational Therapy - (CPG155) |
PDF |
575kB |
04/15/2024 |
| Oncology Imaging Amendment to Cigna-eviCore General Oncology Imaging Guideline - (DV002) |
PDF |
166kB |
07/15/2024 |
| Oncology Imaging Guidelines (Adult and Pediatric) |
Online Resource |
|
|
| Oral Appliances for the Treatment of Obstructive Sleep Apnea - (A016) |
PDf |
208kB |
01/15/2024 |
| Oral Cancer Screening Systems - (0372) |
PDF |
286kB |
11/01/2024 |
| Orthognathic Surgery - (0209) |
PDF |
247kB |
10/15/2024 |
| Orthotic Devices and Shoes - (0543) |
PDF |
806kB |
09/15/2024 |
| Otoplasty and External Ear Reconstruction - (0335) |
PDF |
229kB |
04/15/2024 |
| P |
|
|
|
| Pacemaker |
Online Resource |
|
|
| Pancreatic Islet Cell Transplantation - (0107) |
PDF |
277kB |
06/15/2024 |
| Panniculectomy and Abdominoplasty - (0027) |
PDF |
218kB |
03/15/2024 |
| Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111) |
PDF |
378kB |
07/15/2024 |
| Pediatric Intensive Feeding Programs - (0422) |
PDF |
233kB |
04/01/2024 |
| Pelvic Denervation Procedures - (0368) |
PDF |
229kB |
06/15/2024 |
| Percutaneous Revascularization of the Lower Extermities in Adults - (0537) |
PDF |
|
|
| Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty - (0040) |
PDF |
|
|
| Peripheral Nerve Destruction for Pain Conditions - (0525) |
PDF |
621kB |
02/15/2024 |
| Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation - (0539) |
PDF |
332kB |
03/15/2024 |
| Peripheral Vascular Intervention Clinical Guidelines ---- Replaces CPs 0234, 0537, 0541, 0545 |
Online Resource |
|
11/01/2024 |
| Pharmacogenetic Testing for Non-Cancer Indications - (0500) |
PDF |
352kB |
11/01/2024 |
| Phototherapy, Photochemotherapy, Excimer Laser, Dermabrasion and Chemical Peels for Dermatologic Conditions - (0505) |
PDF |
511kB |
07/15/2024 |
| Physical Performance Test or Measurement - (CPG295) |
PDF |
324kB |
11/15/2024 |
| Physical Therapy - (CPG135) |
PDF |
595kB |
04/15/2024 |
| Plantar Fasciitis Treatments - (0097) |
PDF |
506kB |
02/15/2024 |
| Plasma Brain Natriuretic Peptide in the Outpatient Setting - (0028) |
PDF |
320kB |
05/15/2024 |
| Plasmapheresis - (0153) |
PDF |
481kB |
06/15/2024 |
| Positron Emission Tomography (PET) |
Online Resource |
|
|
| Preventive Care Services - (A004) |
pdf |
573kB |
10/15/2024 |
| Prolotherapy - (CMM 204) |
Online Resource |
|
|
| Prosthetic Devices - (0536) |
PDF |
440kB |
01/15/2024 |
| Proton Beam Therapy |
Online Resource |
|
|
| R |
|
|
|
| Radiation Therapy for Cancers |
Online Resource |
|
|
| Radiofrequency Ablation (RFA) Thyroid Nodules - (0575) |
PDF |
310kB |
10/15/2024 |
| Radiofrequency Joint Ablations / Denervation - (CMM 208) |
Online Resource |
|
|
| Radiofrequency Therapy for Fecal Incontinence - (0576) |
PDF |
193kB |
10/15/2024 |
| Radioimmunotherapy with Zevalin |
Online Resource |
|
|
| Recurrent Pregnancy Loss: Diagnosis and Treatment - (0284) |
PDF |
369kB |
04/15/2024 |
| Redundant Skin Surgery - (0470) |
PDF |
216kB |
06/15/2024 |
| Regional Sympathetic Blocks - (CMM 209) |
Online Resource |
|
|
| Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) - (0563) |
PDF |
366kB |
09/15/2024 |
| Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119) |
PDF |
455kB |
06/15/2024 |
| Rosacea Procedures - (0482) |
PDF |
226kB |
06/15/2024 |
| S |
|
|
|
| Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation - (0404) |
PDF |
363kB |
10/15/2024 |
| Sacroiliac Joint Procedures - (CMM 203) |
Online Resource |
|
|
| Scar Revision - (0328) |
PDF |
390kB |
04/15/2024 |
| Scrotal Ultrasound - (0548) |
PDF |
320kB |
08/15/2024 |
| Seat Lift Mechanism, Patient Lifts and Standing Devices - (0343) |
PDF |
223kB |
05/15/2024 |
| Selective Internal Radiation Therapy (SIRT) |
Online Resource |
|
|
| Sensory and Auditory Integration Therapy - Facilitated Communication - (CPG149) |
PDF |
407kB |
06/15/2024 |
| Serum Folate and Red Blood Cell Folate Testing - (0567) |
PDF |
346kB |
08/17/2024 |
| Shoulder Arthroplasty / Replacement / Resurfacing / Revision / Arthrodesis - (CMM 318) |
Online Resource |
|
|
| Shoulder Surgery - Arthroscopic and Open Procedures - (CMM 315) |
Online Resource |
|
|
| Site of Care: High-tech Radiology - (0550) |
PDF |
176kB |
05/15/2024 |
| Skin Cancer Surveillance Technologies - (0240) |
PDF |
323kB |
10/15/2023 |
| Sleep Management |
Online Resource |
|
|
| Speech Generating Devices - (0049) |
PDF |
194kB |
04/15/2024 |
| Speech Generating Devices - (0049) ---- future effective policy |
PDF |
200kB |
01/15/2025 |
| Speech Therapy - (0177) |
PDF |
456kB |
04/15/2024 |
| Spinal Cord and Dorsal Root Ganglion Stimulation - (CMM 211) |
Online Resource |
|
|
| Spinal Ultrasound - (CPG038) |
PDF |
315kB |
09/15/2024 |
| Staff-Assisted Home Hemodialysis - (0229) |
PDF |
203kB |
11/15/2024 |
| Stem Cell Therapy for Orthopaedic Applications - (0552) |
PDF |
340kB |
11/01/2024 |
| Stem Cell Transplantation: Blood Cancers - (0533) |
PDF |
571kB |
08/15/2024 |
| Stem Cell Transplantation: Non-cancer Disorders - (0535) |
PDF |
450kB |
04/01/2024 |
| Stem Cell Transplantation: Solid Tumors - (0534) |
PDF |
352kB |
01/15/2024 |
| Strapping and Taping - (CPG143) |
PDF |
688kB |
5/15/2024 |
| Subtalar Joint Implantation (Subtalar Arthroereisis) - (0486) |
PDF |
231kB |
10/15/2024 |
| Surgical Treatment for Chest Wall Deformities - (0309) |
PDF |
254kB |
04/15/2024 |
| Surgical Treatment for Hyperhidrosis - (0037) |
PDF |
256kB |
01/15/2024 |
| Surgical Treatments for Obstructive Sleep Apnea - (0158) |
PDF |
383kB |
10/15/2023 |
| T |
|
|
|
| Temporomandibular Joint (TMJ) Disorder Surgery - (0156) |
PDF |
273kB |
12/15/2023 |
| Tests for the Evaluation of Preterm Labor and Premature Rupture of Membranes - (0099) |
PDF |
435kB |
07/15/2024 |
| Thoracic Surgeries and Procedures ---- replaces CPs 0040, 0104, 0393, 0448 |
Online Resource |
|
11/01/2024 |
| Thymus Tissue Transplantation - (0561) |
PDF |
197kB |
08/15/2024 |
| Tilt Table Testing and Computerized Dynamic Posturography - (0270) |
PDF |
243kB |
12/15/2023 |
| Tissue Engineered Skin Substitutes - (0068) |
PDF |
1682kB |
10/18/2024 |
| Tissue-Engineered Skin Substitutes - (0068) ---- future effective policy |
PDF |
1687kB |
01/15/2025 |
| Total Ankle Arthroplasty/Replacement - (0285) |
PDF |
254kB |
04/01/2024 |
| Transcatheter Ablation for the Treatment of Supraventricular Tachycardia in Adults - (0529) |
PDF |
315kB |
04/15/2024 |
| Transcatheter Closure of Cardiovascular Defects - (0011) |
PDF |
119kB |
11/15/2023 |
| Transcatheter Closure of Cardiovascular Defects - (0011) ---- future effective policy |
PDF |
430kB |
02/15/2025 |
| Transcatheter Heart Valve Procedures - (0501) |
PDF |
917kB |
12/03/2023 |
| Transition of Care Service Requests For New Customers - (UM-35) |
PDF |
3137kB |
04/23/2024 |
| Transplantation Donor Charges - (0132) |
PDF |
250kB |
11/15/2024 |
| Transthoracic Echocardiography in Adults - (0510) |
PDF |
757kB |
06/16/2024 |
| Transthoracic Echocardiography in Children - (0523) |
PDF |
809kB |
06/16/2024 |
| Transvaginal Ultrasound, Non-Obstetrical - (0398) |
PDF |
322kB |
12/15/2023 |
| Treatment of Cutaneous and/or Deep Tissue Hemangioma, Port Wine Stain and Other Vascular Lesions - (0313) |
PDF |
300kB |
11/15/2024 |
| Trigger Point Injections - (0139) |
PDF |
189kB |
11/01/2024 |
| Tumor In Vitro Chemosensitivity and Chemoresistance Assays - (0203) |
PDF |
322kB |
05/15/2024 |
| Tympanostomy with Iontophoresis Local Anesthesia - (0570) |
PDF |
239kB |
07/15/2024 |
| U |
|
|
|
| Ultrasound in Pregnancy (including 3D, 4D and 5D Ultrasound) - (0142) |
PDF |
231kB |
06/15/2024 |
| Umbilical Cord Blood Banking - (0466) |
PDF |
214kB |
06/15/2024 |
| V |
|
|
|
| Vagus Nerve Stimulation (VNS) - (0350) |
PDF |
429kB |
04/01/2024 |
| Varicose Vein Treatments - (0234) |
PDF |
|
|
| Vascularized Composite Allograft (VCA) Transplant - (0560) |
PDF |
262kB |
01/15/2024 |
| Venous Angioplasty and/or Stent Placement in Adults - (0541) |
PDF |
|
|
| Ventricular Assist Devices (VADs), Percutaneous Cardiac Support Systems and Total Artificial Heart - (0054) |
PDF |
652kB |
04/01/2024 |
| Ventricular Assist Devices (VADs), Percutaneous Cardiac Support Systems and Total Artificial Heart - (0054) ---- future effective policy |
PDF |
645kB |
01/15/2025 |
| Vitamin D Testing - (0526) |
PDF |
269kB |
08/15/2024 |
| W |
|
|
|
| Wheelchairs/Power Operated Vehicles - (0030) |
PDF |
527kB |
04/15/2024 |
| Whole Exome and Whole Genome Sequencing for Non-Cancer Indications - (0519) |
PDF |
|
|
| Whole Exome Sequencing Recommendation Form ---- retired |
Online Resource |
|
11/01/2024 |
| Wide-Area Transepithelial Tissue Sampling with Computer-Assisted 3D Analysis (WATS3D) - (0578) |
PDF |
278kB |
11/15/2024 |