AE
Aetna
Updated
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Ravulizumab-cwvz (Ultomiris) - CPB 0946AN
Anthem Blue Cross Blue Shield Missouri
Updated
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CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
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CG-DME-13 Lower Limb ProsthesisUpdated
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CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
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CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
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CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
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CG-MED-95 Transanal IrrigationUpdated
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CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
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MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
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SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
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Updated
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CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
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CG-DME-13 Lower Limb ProsthesisUpdated
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CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
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CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
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CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
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CG-MED-95 Transanal IrrigationUpdated
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CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
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MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
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SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
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Updated
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CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
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CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
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CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
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CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
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MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
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SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield Ohio
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
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CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
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CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
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CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
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CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
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SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
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Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
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CG-DME-13 Lower Limb ProsthesisUpdated
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CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
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CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
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CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalSURG.00011Updated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of Colorado
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverCG-SURG-61Updated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalSURG.00011Updated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of Connecticut
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverCG-SURG-61Updated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalSURG.00011Updated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of Georgia
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverCG-SURG-61Updated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
MED.00129 Gene Therapy for Spinal Muscular AtrophyUpdated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalSURG.00011Updated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of Indiana
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverCG-SURG-61Updated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
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TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of Maine
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
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CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
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CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
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MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
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TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of New York
Updated
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CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
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CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
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CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
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SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalSURG.00011Updated
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalUpdated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of Virginia
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
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CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
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CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverCG-SURG-61Updated
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MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
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TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem Blue Cross Blue Shield of Wisconsin
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
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CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
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CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
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CG-MED-95 Transanal IrrigationCG-MED-95Updated
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CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
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CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverCG-SURG-61Updated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
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TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsAN
Anthem BlueCross BlueShield Kentucky
Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsCG-ANC-08Updated
CG-ANC-08 Mobile Device-Based Health Management ApplicationsUpdated
CG-DME-13 Lower Limb ProsthesisCG-DME-13Updated
CG-DME-13 Lower Limb ProsthesisUpdated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesCG-DME-22Updated
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot OrthosesUpdated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44Updated
CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyUpdated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49Updated
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersUpdated
CG-MED-95 Transanal IrrigationCG-MED-95Updated
CG-MED-95 Transanal IrrigationUpdated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesCG-SURG-127Updated
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary UsesUpdated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverCG-SURG-61Updated
CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the LiverUpdated
MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129Updated
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SURG.00011 Products for Wound Healing and Soft Tissue Grafting: InvestigationalSURG.00011Updated
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TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035Updated
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsBL
Blue Cross Blue Shield Oklahoma
New
Laboratory Testing Investigational ServicesMED207.164New
Laboratory Testing Investigational ServicesUpdated
AbataceptRX501.113Updated
Anifrolumab-fniaRX501.138Updated
Avacincaptad pegolOTH903.045Updated
Avacincaptad pegolUpdated
Burosumab-twzaRX502.058Updated
Certolizumab PegolRX501.111Updated
Certolizumab PegolUpdated
Crizanlizumab-tmcaRX501.126Updated
Crizanlizumab-tmcaUpdated
EdaravoneRX501.095Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementSUR701.043Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementUpdated
Eptinezumab-jjmrRX501.124Updated
Extracranial Carotid Angioplasty or StentingSUR701.028Updated
Extracranial Carotid Angioplasty or StentingUpdated
Ibalizumab-uiykRX501.099Updated
Intracellular Micronutrient AnalysisMED207.088Updated
Intracellular Micronutrient AnalysisUpdated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityDME102.009Updated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityUpdated
KidneyIntelX and KidneyIntelX.dkd TestingMED207.163Updated
KidneyIntelX and KidneyIntelX.dkd TestingUpdated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVRX501.145Updated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVUpdated
Mirikizumab-mrkzRX501.168Updated
Nonwearable Automatic External DefibrillatorsDME101.021Updated
Nonwearable Automatic External DefibrillatorsUpdated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqRX501.085Updated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqUpdated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaMED201.025Updated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaUpdated
Teplizumab-mzwvRX501.150Updated
Teprotumumab-trbwRX501.110Updated
Tocilizumab and Associated Biosimilar(s)RX501.115Updated
Tocilizumab and Associated Biosimilar(s)Updated
Triamcinolone acetonideOTH903.035Updated
Triamcinolone acetonideUpdated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeSUR705.024Updated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeUpdated
VedolizumabRX501.117BL
Blue Cross Blue Shield of Florida
New
Immunoglobulin A Nephropathy (IgAN)09-J5000-34New
Immunoglobulin A Nephropathy (IgAN)New
Interstitial Lung Disease (ILD)09-J5000-48New
Interstitial Lung Disease (ILD)Updated
Adalimumab Products (Humira and biosimilars)09-J0000-46Updated
Adalimumab Products (Humira and biosimilars)Updated
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer05-86000-26Updated
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast CancerUpdated
Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid02-10000-11Updated
Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic FluidUpdated
Denosumab (Prolia, Xgeva) Injection09-J1000-25Updated
Denosumab (Prolia, Xgeva) InjectionUpdated
Drugs and Biologics without Medical Coverage Guideline09-J0000-68Updated
Drugs and Biologics without Medical Coverage GuidelineUpdated
Gonadotropin Releasing Hormone Analogs and Antagonists09-J0000-48Updated
Gonadotropin Releasing Hormone Analogs and AntagonistsUpdated
Immune Globulin Therapy09-J0000-06Updated
Immune Globulin TherapyUpdated
Lecanemab-irmb (Leqembi, Leqembi Iqlik) intravenous infusion and SQ injection09-J4000-41Updated
Lecanemab-irmb (Leqembi, Leqembi Iqlik) intravenous infusion and SQ injectionUpdated
Linvoseltamab-gcpt (Lynozyfic) IV Infusion09-J5000-27Updated
Linvoseltamab-gcpt (Lynozyfic) IV InfusionUpdated
Medical & Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal Passages02-40000-16Updated
Medical & Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal PassagesUpdated
Myoelectric Prosthetic and Orthotic Components for the Upper Limb09-L0000-07Updated
Myoelectric Prosthetic and Orthotic Components for the Upper LimbUpdated
Octreotide Acetate (Sandostatin LAR Depot, Mycapssa Capsule)09-J0000-90Updated
Octreotide Acetate (Sandostatin LAR Depot, Mycapssa Capsule)Updated
Pembrolizumab (Keytruda, Keytruda Qlex) Injection09-J2000-22Updated
Pembrolizumab (Keytruda, Keytruda Qlex) InjectionUpdated
Tocilizumab Products (Actemra and Tyenne Injections, and Actemra, Avtozma, Tofidence, and Tyenne Infusions)09-J1000-21Updated
Tocilizumab Products (Actemra and Tyenne Injections, and Actemra, Avtozma, Tofidence, and Tyenne Infusions)Updated
Zopapogene imadenovec-drba (Papzimeos) SQ Injection09-J5000-29Updated
Zopapogene imadenovec-drba (Papzimeos) SQ InjectionBL
Blue Cross Blue Shield of Illinois
New
Laboratory Testing Investigational ServicesMED207.164New
Laboratory Testing Investigational ServicesUpdated
AbataceptRX501.113Updated
Anifrolumab-fniaRX501.138Updated
Avacincaptad pegolOTH903.045Updated
Avacincaptad pegolUpdated
Burosumab-twzaRX502.058Updated
Certolizumab PegolRX501.111Updated
Certolizumab PegolUpdated
Crizanlizumab-tmcaRX501.126Updated
Crizanlizumab-tmcaUpdated
EdaravoneRX501.095Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementSUR701.043Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementUpdated
Eptinezumab-jjmrRX501.124Updated
Extracranial Carotid Angioplasty or StentingSUR701.028Updated
Extracranial Carotid Angioplasty or StentingUpdated
Ibalizumab-uiykRX501.099Updated
Intracellular Micronutrient AnalysisMED207.088Updated
Intracellular Micronutrient AnalysisUpdated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityDME102.009Updated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityUpdated
KidneyIntelX and KidneyIntelX.dkd TestingMED207.163Updated
KidneyIntelX and KidneyIntelX.dkd TestingUpdated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVRX501.145Updated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVUpdated
Mirikizumab-mrkzRX501.168Updated
Nonwearable Automatic External DefibrillatorsDME101.021Updated
Nonwearable Automatic External DefibrillatorsUpdated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqRX501.085Updated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqUpdated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaMED201.025Updated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaUpdated
Teplizumab-mzwvRX501.150Updated
Teprotumumab-trbwRX501.110Updated
Tocilizumab and Associated Biosimilar(s)RX501.115Updated
Tocilizumab and Associated Biosimilar(s)Updated
Triamcinolone acetonideOTH903.035Updated
Triamcinolone acetonideUpdated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeSUR705.024Updated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeUpdated
VedolizumabRX501.117BL
Blue Cross Blue Shield of Montana
New
Laboratory Testing Investigational ServicesMED207.164New
Laboratory Testing Investigational ServicesUpdated
AbataceptRX501.113Updated
Anifrolumab-fniaRX501.138Updated
Avacincaptad pegolOTH903.045Updated
Avacincaptad pegolUpdated
Burosumab-twzaRX502.058Updated
Certolizumab PegolRX501.111Updated
Certolizumab PegolUpdated
Crizanlizumab-tmcaRX501.126Updated
Crizanlizumab-tmcaUpdated
EdaravoneRX501.095Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementSUR701.043Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementUpdated
Eptinezumab-jjmrRX501.124Updated
Extracranial Carotid Angioplasty or StentingSUR701.028Updated
Extracranial Carotid Angioplasty or StentingUpdated
Ibalizumab-uiykRX501.099Updated
Intracellular Micronutrient AnalysisMED207.088Updated
Intracellular Micronutrient AnalysisUpdated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityDME102.009Updated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityUpdated
KidneyIntelX and KidneyIntelX.dkd TestingMED207.163Updated
KidneyIntelX and KidneyIntelX.dkd TestingUpdated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVRX501.145Updated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVUpdated
Mirikizumab-mrkzRX501.168Updated
Nonwearable Automatic External DefibrillatorsDME101.021Updated
Nonwearable Automatic External DefibrillatorsUpdated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqRX501.085Updated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqUpdated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaMED201.025Updated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaUpdated
Teplizumab-mzwvRX501.150Updated
Teprotumumab-trbwRX501.110Updated
Tocilizumab and Associated Biosimilar(s)RX501.115Updated
Tocilizumab and Associated Biosimilar(s)Updated
Triamcinolone acetonideOTH903.035Updated
Triamcinolone acetonideUpdated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeSUR705.024Updated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeUpdated
VedolizumabRX501.117BL
Blue Cross Blue Shield of New Mexico
New
Laboratory Testing Investigational ServicesMED207.164New
Laboratory Testing Investigational ServicesUpdated
AbataceptRX501.113Updated
Anifrolumab-fniaRX501.138Updated
Avacincaptad pegolOTH903.045Updated
Avacincaptad pegolUpdated
Burosumab-twzaRX502.058Updated
Certolizumab PegolRX501.111Updated
Certolizumab PegolUpdated
Crizanlizumab-tmcaRX501.126Updated
Crizanlizumab-tmcaUpdated
EdaravoneRX501.095Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementSUR701.043Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementUpdated
Eptinezumab-jjmrRX501.124Updated
Extracranial Carotid Angioplasty or StentingSUR701.028Updated
Extracranial Carotid Angioplasty or StentingUpdated
Ibalizumab-uiykRX501.099Updated
Intracellular Micronutrient AnalysisMED207.088Updated
Intracellular Micronutrient AnalysisUpdated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityDME102.009Updated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityUpdated
KidneyIntelX and KidneyIntelX.dkd TestingMED207.163Updated
KidneyIntelX and KidneyIntelX.dkd TestingUpdated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVRX501.145Updated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVUpdated
Mirikizumab-mrkzRX501.168Updated
Nonwearable Automatic External DefibrillatorsDME101.021Updated
Nonwearable Automatic External DefibrillatorsUpdated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqRX501.085Updated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqUpdated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaMED201.025Updated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaUpdated
Teplizumab-mzwvRX501.150Updated
Teprotumumab-trbwRX501.110Updated
Tocilizumab and Associated Biosimilar(s)RX501.115Updated
Tocilizumab and Associated Biosimilar(s)Updated
Triamcinolone acetonideOTH903.035Updated
Triamcinolone acetonideUpdated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeSUR705.024Updated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeUpdated
VedolizumabRX501.117BL
Blue Cross Blue Shield of Texas
New
Laboratory Testing Investigational ServicesMED207.164New
Laboratory Testing Investigational ServicesUpdated
AbataceptRX501.113Updated
Anifrolumab-fniaRX501.138Updated
Avacincaptad pegolOTH903.045Updated
Avacincaptad pegolUpdated
Burosumab-twzaRX502.058Updated
Certolizumab PegolRX501.111Updated
Certolizumab PegolUpdated
Crizanlizumab-tmcaRX501.126Updated
Crizanlizumab-tmcaUpdated
EdaravoneRX501.095Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementSUR701.043Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementUpdated
Eptinezumab-jjmrRX501.124Updated
Extracranial Carotid Angioplasty or StentingSUR701.028Updated
Extracranial Carotid Angioplasty or StentingUpdated
Ibalizumab-uiykRX501.099Updated
Intracellular Micronutrient AnalysisMED207.088Updated
Intracellular Micronutrient AnalysisUpdated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityDME102.009Updated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityUpdated
KidneyIntelX and KidneyIntelX.dkd TestingMED207.163Updated
KidneyIntelX and KidneyIntelX.dkd TestingUpdated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVRX501.145Updated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVUpdated
Mirikizumab-mrkzRX501.168Updated
Nonwearable Automatic External DefibrillatorsDME101.021Updated
Nonwearable Automatic External DefibrillatorsUpdated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqRX501.085Updated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqUpdated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaMED201.025Updated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaUpdated
Teplizumab-mzwvRX501.150Updated
Teprotumumab-trbwRX501.110Updated
Tocilizumab and Associated Biosimilar(s)RX501.115Updated
Tocilizumab and Associated Biosimilar(s)Updated
Triamcinolone acetonideOTH903.035Updated
Triamcinolone acetonideUpdated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeSUR705.024Updated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeUpdated
VedolizumabRX501.117BL
Blue Cross Illinois Medicare Advantage
New
Laboratory Testing Investigational ServicesMED207.164New
Laboratory Testing Investigational ServicesUpdated
AbataceptRX501.113Updated
Anifrolumab-fniaRX501.138Updated
Avacincaptad pegolOTH903.045Updated
Avacincaptad pegolUpdated
Burosumab-twzaRX502.058Updated
Certolizumab PegolRX501.111Updated
Certolizumab PegolUpdated
Crizanlizumab-tmcaRX501.126Updated
Crizanlizumab-tmcaUpdated
EdaravoneRX501.095Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementSUR701.043Updated
Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient MeasurementUpdated
Eptinezumab-jjmrRX501.124Updated
Extracranial Carotid Angioplasty or StentingSUR701.028Updated
Extracranial Carotid Angioplasty or StentingUpdated
Ibalizumab-uiykRX501.099Updated
Intracellular Micronutrient AnalysisMED207.088Updated
Intracellular Micronutrient AnalysisUpdated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityDME102.009Updated
Intraurethral Valve Drainage Device for Impaired Detrusor ContractilityUpdated
KidneyIntelX and KidneyIntelX.dkd TestingMED207.163Updated
KidneyIntelX and KidneyIntelX.dkd TestingUpdated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVRX501.145Updated
Long-Acting Injectable Antiretroviral Agents for Treatment of HIVUpdated
Mirikizumab-mrkzRX501.168Updated
Nonwearable Automatic External DefibrillatorsDME101.021Updated
Nonwearable Automatic External DefibrillatorsUpdated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqRX501.085Updated
Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsqUpdated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaMED201.025Updated
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic HyperplasiaUpdated
Teplizumab-mzwvRX501.150Updated
Teprotumumab-trbwRX501.110Updated
Tocilizumab and Associated Biosimilar(s)RX501.115Updated
Tocilizumab and Associated Biosimilar(s)Updated
Triamcinolone acetonideOTH903.035Updated
Triamcinolone acetonideUpdated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeSUR705.024Updated
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the KneeUpdated
VedolizumabRX501.117BL
Blue Shield of California
New
Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA2.04.108New
Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNANew
narsoplimab-wuug (Yartemlea)narsoplimab-wuug-Yartemlea-COMM-UMRx-providerNew
narsoplimab-wuug (Yartemlea)narsoplimab-wuug-Yartemlea-COMM-UMRx-provider New
pegzilarginase-nbln (Loargys)pegzilarginase-nbln-Loargys-COMM-UMRx-providerNew
pegzilarginase-nbln (Loargys)pegzilarginase-nbln-Loargys-COMM-UMRx-provider Updated
ADAMTS13, recombinant-krhn (Adzynma)adamts13-recombinant-krhn-Adzynma-COMM-UMRx-providerUpdated
ADAMTS13, recombinant-krhn (Adzynma)adamts13-recombinant-krhn-Adzynma-COMM-UMRx-provider Updated
Ablation of Peripheral Nerves to Treat Pain7.01.154Updated
Ablation of Peripheral Nerves to Treat PainUpdated
Amniotic Membrane and Amniotic Fluid7.01.149Updated
Amniotic Membrane and Amniotic FluidUpdated
Bariatric Surgery7.01.47Updated
Baroreflex Stimulation Devices8.01.57Updated
Baroreflex Stimulation DevicesUpdated
Bioengineered Skin and Soft Tissue Substitutes7.01.113Updated
Bioengineered Skin and Soft Tissue SubstitutesUpdated
Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)BSC7.01Updated
Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)Updated
C1 esterase inhibitor (Cinryze)c1-esterase-inhibitor-human-Cinryze-COMM-UMRx-providerUpdated
C1 esterase inhibitor (Cinryze)c1-esterase-inhibitor-human-Cinryze-COMM-UMRx-provider Updated
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)2.04.141Updated
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)Updated
Cleft Palate - Dental Related ServicesBSC2.01Updated
Cleft Palate - Dental Related ServicesUpdated
Continuous Glucose Monitoring1.01.20Updated
Continuous Glucose MonitoringUpdated
Cooling Devices Used in the Outpatient Setting1.01.26Updated
Cooling Devices Used in the Outpatient SettingUpdated
Cranial Electrotherapy Stimulation and Auricular Electrostimulation8.01.58Updated
Cranial Electrotherapy Stimulation and Auricular ElectrostimulationUpdated
Elective Invasive Coronary Angiography (ICA)BSC2.13Updated
Elective Invasive Coronary Angiography (ICA)Updated
Elective Percutaneous Coronary Intervention (PCI)BSC6.02Updated
Elective Percutaneous Coronary Intervention (PCI)Updated
Electromagnetic Navigational Bronchoscopy7.01.122Updated
Electromagnetic Navigational BronchoscopyUpdated
Focal Treatments for Prostate Cancer8.01.61Updated
Focal Treatments for Prostate CancerUpdated
Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing2.04.93Updated
Genetic Cancer Susceptibility Panels Using Next-Generation SequencingUpdated
Genetic Testing for Cardiac Ion Channelopathies2.04.43Updated
Genetic Testing for Cardiac Ion ChannelopathiesUpdated
Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies2.04.59Updated
Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital AnomaliesUpdated
Genetic Testing for FMR1 Variants (Including Fragile X Syndrome)2.04.83Updated
Genetic Testing for FMR1 Variants (Including Fragile X Syndrome)Updated
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer2.04.33Updated
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate CancerUpdated
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)2.04.02Updated
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)Updated
Identification of Microorganisms Using Nucleic Acid Probes2.04.10Updated
Identification of Microorganisms Using Nucleic Acid ProbesUpdated
Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions1.01.31Updated
Implantable Peripheral Nerve Stimulation for Chronic Pain ConditionsUpdated
Investigational ServicesBSC9.01Updated
Investigational ServicesUpdated
Laboratory Testing Investigational Services2.04.159Updated
Laboratory Testing Investigational ServicesUpdated
Lysis of Epidural AdhesionsBSC8.05Updated
Lysis of Epidural AdhesionsUpdated
Negative Pressure Wound Therapy in the Outpatient Setting1.01.16Updated
Negative Pressure Wound Therapy in the Outpatient SettingUpdated
Octreotide (Sandostatin) intravenous and Octreotide LAR (Sandostatin LAR)octreotide-Sandostatin-IV-or-LAR-Depot-COMM-UMRx-providerUpdated
Octreotide (Sandostatin) intravenous and Octreotide LAR (Sandostatin LAR)octreotide-Sandostatin-IV-or-LAR-Depot-COMM-UMRx-provider Updated
Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow)8.01.52Updated
Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow)Updated
Pegfilgrastim (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo)pegfilgrastim-COMM-UMRx-providerUpdated
Pegfilgrastim (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo)pegfilgrastim-COMM-UMRx-provider Updated
Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome2.01.106Updated
Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel SyndromeUpdated
Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease7.01.178Updated
Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial DiseaseUpdated
Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts7.01.177Updated
Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve AllograftsUpdated
Pharmacogenetic Testing for Pain Management2.04.131Updated
Pharmacogenetic Testing for Pain ManagementUpdated
Reduction Mammaplasty for Breast-Related Symptoms7.01.21Updated
Reduction Mammaplasty for Breast-Related SymptomsUpdated
Remote Electrical Neuromodulation for Migraines7.01.171Updated
Remote Electrical Neuromodulation for MigrainesUpdated
Reproductive Techniques4.02.04Updated
Reproductive TechniquesUpdated
Temporomandibular Joint Disorder2.01.21Updated
Temporomandibular Joint DisorderUpdated
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy2.01.49Updated
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic HypertrophyUpdated
Treatment of Varicose Veins/Venous Insufficiency7.01.124Updated
Treatment of Varicose Veins/Venous InsufficiencyUpdated
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance2.04.07Updated
Urinary Biomarkers for Cancer Screening, Diagnosis, and SurveillanceUpdated
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders2.04.102Updated
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic DisordersUpdated
allergen extract (Grastek, Odactra, Oralair, Ragwitek)sublingual-allergen-immunotherapy-COMM-UMRx-providerUpdated
allergen extract (Grastek, Odactra, Oralair, Ragwitek)sublingual-allergen-immunotherapy-COMM-UMRx-provider Updated
brolucizumab-dbll (Beovu)brolucizumab-dbll-Beovu-COMM-UMRx-providerUpdated
brolucizumab-dbll (Beovu)brolucizumab-dbll-Beovu-COMM-UMRx-provider Updated
collagenase clostridium histolyticum (Xiaflex)collagenase-clostridium-histolyticum-Xiaflex-COMM-UMRx-providerUpdated
collagenase clostridium histolyticum (Xiaflex)collagenase-clostridium-histolyticum-Xiaflex-COMM-UMRx-provider Updated
daxibotulinumtoxinA-lanm (Daxxify)daxibotulinumtoxina-lanm-Daxxify-COMM-UMRx-providerUpdated
daxibotulinumtoxinA-lanm (Daxxify)daxibotulinumtoxina-lanm-Daxxify-COMM-UMRx-provider Updated
degarelix (Firmagon)degarelix-Firmagon-COMM-UMRx-providerUpdated
degarelix (Firmagon)degarelix-Firmagon-COMM-UMRx-provider Updated
denosumab (Prolia, Bildyos, Bosaya, Conexxence, Enoby, Jubbonti, Ospomyv, Stoboclo)denosumab-Prolia-and-biosimilars-COMM-UMRx-providerUpdated
denosumab (Prolia, Bildyos, Bosaya, Conexxence, Enoby, Jubbonti, Ospomyv, Stoboclo)denosumab-Prolia-and-biosimilars-COMM-UMRx-provider Updated
etranacogene-dezaparvovec (Hemgenix)etranacogene-dezaparvovec-drlb-Hemgenix-COMM-UMRx-providerUpdated
etranacogene-dezaparvovec (Hemgenix)etranacogene-dezaparvovec-drlb-Hemgenix-COMM-UMRx-provider Updated
filgrastim (Neupogen, Nivestym, Nypozi, Releuko, Zarxio)filgrastim-COMM-UMRx-providerUpdated
filgrastim (Neupogen, Nivestym, Nypozi, Releuko, Zarxio)filgrastim-COMM-UMRx-provider Updated
immune globulin, intravenous (Alyglo, Asceniv, Bivigam, Cytogam, Gammagard liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Qivigy, Yimmugo)intravenous-immune-globulin-IVIG-COMM-UMRx-providerUpdated
immune globulin, intravenous (Alyglo, Asceniv, Bivigam, Cytogam, Gammagard liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Qivigy, Yimmugo)intravenous-immune-globulin-IVIG-COMM-UMRx-provider Updated
ketamine (Ketalar)ketamine-COMM-UMRx-providerUpdated
ketamine (Ketalar)ketamine-COMM-UMRx-provider Updated
lanreotide (Somatuline)lanreotide-COMM-UMRx-providerUpdated
lanreotide (Somatuline)lanreotide-COMM-UMRx-provider Updated
lecanemab-irmb (Leqembi)lecanemab-irmb-Leqembi-COMM-UMRx-providerUpdated
lecanemab-irmb (Leqembi)lecanemab-irmb-Leqembi-COMM-UMRx-provider Updated
lenacapavir (Sunlenca)lenacapavir-Sunlenca-COMM-UMRx-providerUpdated
lenacapavir (Sunlenca)lenacapavir-Sunlenca-COMM-UMRx-provider Updated
leuprolide (Camcevi)leuprolide-mesylate-Camcevi-COMM-UMRx-providerUpdated
leuprolide (Camcevi)leuprolide-mesylate-Camcevi-COMM-UMRx-provider Updated
leuprolide acetate (Fensolvi)leuprolide-acetate-Fensolvi-COMM-UMRx-providerUpdated
leuprolide acetate (Fensolvi)leuprolide-acetate-Fensolvi-COMM-UMRx-provider Updated
lumasiran (Oxlumo)lumasiran-Oxlumo-COMM-UMRx-providerUpdated
lumasiran (Oxlumo)lumasiran-Oxlumo-COMM-UMRx-provider Updated
miglustat (Opfolda)miglustat-Opfolda-COMM-UMRx-providerUpdated
miglustat (Opfolda)miglustat-Opfolda-COMM-UMRx-provider Updated
onasemnogene abeparvovec-brve (Itvisma)onasemnogene-abeparvovec-brve-Itvisma-COMM-UMRx-providerUpdated
onasemnogene abeparvovec-brve (Itvisma)onasemnogene-abeparvovec-brve-Itvisma-COMM-UMRx-provider Updated
ranibizumab (Lucentis)ranibizumab-Lucentis-COMM-UMRx-providerUpdated
ranibizumab (Lucentis)ranibizumab-Lucentis-COMM-UMRx-provider Updated
ranibizumab intravitreal implant (Susvimo)ranibizumab-implant-Susvimo-COMM-UMRx-providerUpdated
ranibizumab intravitreal implant (Susvimo)ranibizumab-implant-Susvimo-COMM-UMRx-provider Updated
ranibizumab-eqrn (Cimerli)ranibizumab-eqrn-Cimerli-COMM-UMRx-providerUpdated
ranibizumab-eqrn (Cimerli)ranibizumab-eqrn-Cimerli-COMM-UMRx-provider Updated
ranibizumab-nuna (Byooviz)ranibizumab-nuna-Byooviz-COMM-UMRx-providerUpdated
ranibizumab-nuna (Byooviz)ranibizumab-nuna-Byooviz-COMM-UMRx-provider Updated
romiplostim (Nplate)romiplostim-Nplate-COMM-UMRx-providerUpdated
romiplostim (Nplate)romiplostim-Nplate-COMM-UMRx-provider Updated
sargramostim (Leukine)sargramostim-Leukine-IV-and-SC-COMM-UMRx-providerUpdated
sargramostim (Leukine)sargramostim-Leukine-IV-and-SC-COMM-UMRx-provider Updated
tbo-filgrastim (Granix)tbo-filgrastim-Granix-COMM-UMRx-providerUpdated
tbo-filgrastim (Granix)tbo-filgrastim-Granix-COMM-UMRx-provider Updated
teduglutide (Gattex)teduglutide-Gattex-COMM-UMRx-providerUpdated
teduglutide (Gattex)teduglutide-Gattex-COMM-UMRx-provider Updated
teplizumab-mzwv (Tzield)teplizumab-mzwv-Tzield-COMM-UMRx-providerUpdated
teplizumab-mzwv (Tzield)teplizumab-mzwv-Tzield-COMM-UMRx-provider Updated
tocilizumab (Actemra, Avtozma, Tofidence, Tyenne), intravenoustocilizumab-intravenous-COMM-UMRx-providerUpdated
tocilizumab (Actemra, Avtozma, Tofidence, Tyenne), intravenoustocilizumab-intravenous-COMM-UMRx-provider Updated
zopapogene imadenovec-drba (Papzimeos)zopapogene-imadenovec-drba-Papzimeos-COMM-UMRx-providerUpdated
zopapogene imadenovec-drba (Papzimeos)zopapogene-imadenovec-drba-Papzimeos-COMM-UMRx-provider HU
Humana
New
Computer Assisted Surgical Navigation for Musculoskeletal Procedures - Medicare AdvantageHUM-1293-000New
Computer Assisted Surgical Navigation for Musculoskeletal Procedures - Medicare AdvantageUpdated
Artificial Intervertebral Disc Replacement - Medicare AdvantageHUM-1013-003Updated
Artificial Intervertebral Disc Replacement - Medicare AdvantageUpdated
Cardiac Catheterization and Coronary Angiography - Medicare AdvantageHUM-1034-006Updated
Cardiac Catheterization and Coronary Angiography - Medicare AdvantageUpdated
Cardiac Magnetic Resonance Imaging (MRI) - Medicare AdvantageHUM-1291-000Updated
Cardiac Magnetic Resonance Imaging (MRI) - Medicare AdvantageUpdated
Colorectal Cancer Screening - Medicare AdvantageHUM-1054-008Updated
Colorectal Cancer Screening - Medicare AdvantageUpdated
Comprehensive Genomic Profiling and Multigene Panel Testing for Solid Tumors - Medicare AdvantageHUM-1057-009Updated
Comprehensive Genomic Profiling and Multigene Panel Testing for Solid Tumors - Medicare AdvantageUpdated
Facility Based Sleep Studies - Medicare AdvantageHUM-1255-007Updated
Facility Based Sleep Studies - Medicare AdvantageUpdated
Genetic Testing for Hematologic Malignancies and Suspected Myeloid Disorders - Medicare AdvantageHUM-1240-010Updated
Genetic Testing for Hematologic Malignancies and Suspected Myeloid Disorders - Medicare AdvantageUpdated
Genetic Testing for Hereditary Colorectal and Uterine Cancer - Medicare AdvantageHUM-1106-008Updated
Genetic Testing for Hereditary Colorectal and Uterine Cancer - Medicare AdvantageUpdated
Glaucoma Surgical Treatments - Medicare AdvantageHUM-1119-004Updated
Glaucoma Surgical Treatments - Medicare AdvantageUpdated
Hyperthermia and Ultrasound-Based Ablative Cancer Treatments - Medicare AdvantageHUM-1130-007Updated
Hyperthermia and Ultrasound-Based Ablative Cancer Treatments - Medicare AdvantageUpdated
Low Frequency, Non-Contact, Non-Thermal Ultrasound for Wound Care - Medicare AdvantageHUM-1272-002Updated
Low Frequency, Non-Contact, Non-Thermal Ultrasound for Wound Care - Medicare AdvantageUpdated
Nerve Stimulation for Urinary Incontinence - Medicare AdvantageHUM-1230-007Updated
Nerve Stimulation for Urinary Incontinence - Medicare AdvantageUpdated
Nuclear Imaging for Cancer Indications - Medicare AdvantageHUM-1087-010Updated
Nuclear Imaging for Cancer Indications - Medicare AdvantageUpdated
Nuclear Imaging for Noncancer Indications - Medicare AdvantageHUM-1088-006Updated
Nuclear Imaging for Noncancer Indications - Medicare AdvantageUpdated
Sinonasal and Eustachian Tube Surgical Procedures - Medicare AdvantageHUM-1019-006Updated
Sinonasal and Eustachian Tube Surgical Procedures - Medicare AdvantageUpdated
Upper and Lower Extremity Magnetic Resonance Imaging (MRI) - Medicare AdvantageHUM-1296-000Updated
Upper and Lower Extremity Magnetic Resonance Imaging (MRI) - Medicare AdvantageUpdated
Uterine Fibroid Surgical Treatments - Medicare AdvantageHUM-1231-004Updated
Uterine Fibroid Surgical Treatments - Medicare AdvantageUpdated
Varicose Vein Treatments - Medicare AdvantageHUM-1233-004Updated
Varicose Vein Treatments - Medicare AdvantageME
Medicare Florida Blue
New
Immunoglobulin A Nephropathy (IgAN)09-J5000-34New
Immunoglobulin A Nephropathy (IgAN)New
Interstitial Lung Disease (ILD)09-J5000-48New
Interstitial Lung Disease (ILD)Updated
Adalimumab Products (Humira and biosimilars)09-J0000-46Updated
Adalimumab Products (Humira and biosimilars)Updated
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer05-86000-26Updated
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast CancerUpdated
Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid02-10000-11Updated
Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic FluidUpdated
Denosumab (Prolia, Xgeva) Injection09-J1000-25Updated
Denosumab (Prolia, Xgeva) InjectionUpdated
Drugs and Biologics without Medical Coverage Guideline09-J0000-68Updated
Drugs and Biologics without Medical Coverage GuidelineUpdated
Gonadotropin Releasing Hormone Analogs and Antagonists09-J0000-48Updated
Gonadotropin Releasing Hormone Analogs and AntagonistsUpdated
Immune Globulin Therapy09-J0000-06Updated
Immune Globulin TherapyUpdated
Lecanemab-irmb (Leqembi, Leqembi Iqlik) intravenous infusion and SQ injection09-J4000-41Updated
Lecanemab-irmb (Leqembi, Leqembi Iqlik) intravenous infusion and SQ injectionUpdated
Linvoseltamab-gcpt (Lynozyfic) IV Infusion09-J5000-27Updated
Linvoseltamab-gcpt (Lynozyfic) IV InfusionUpdated
Medical & Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal Passages02-40000-16Updated
Medical & Surgical Management of Sleep Apnea, Snoring, and Other Conditions of the Soft Palate and Nasal PassagesUpdated
Myoelectric Prosthetic and Orthotic Components for the Upper Limb09-L0000-07Updated
Myoelectric Prosthetic and Orthotic Components for the Upper LimbUpdated
Octreotide Acetate (Sandostatin LAR Depot, Mycapssa Capsule)09-J0000-90Updated
Octreotide Acetate (Sandostatin LAR Depot, Mycapssa Capsule)Updated
Pembrolizumab (Keytruda, Keytruda Qlex) Injection09-J2000-22Updated
Pembrolizumab (Keytruda, Keytruda Qlex) InjectionUpdated
Tocilizumab Products (Actemra and Tyenne Injections, and Actemra, Avtozma, Tofidence, and Tyenne Infusions)09-J1000-21Updated
Tocilizumab Products (Actemra and Tyenne Injections, and Actemra, Avtozma, Tofidence, and Tyenne Infusions)Updated
Zopapogene imadenovec-drba (Papzimeos) SQ Injection09-J5000-29Updated
Zopapogene imadenovec-drba (Papzimeos) SQ Injection