Policy updates

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Jul 16, 2026

Aetna

Updated

Biofeedback - CPB 01320132

Updated

Biofeedback - CPB 0132

0132

Updated

Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments- CPB 04470447

Updated

Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments- CPB 0447

0447

Updated

Foot Orthotics - CPB 04510451

Updated

Foot Orthotics - CPB 0451

0451

Updated

Hematopoietic Colony-Stimulating Factors (CSFs) - CPB 00550055

Updated

Hematopoietic Colony-Stimulating Factors (CSFs) - CPB 0055

0055

Updated

Infertility - CPB 03270327

Updated

Infertility - CPB 0327

0327

Updated

Obsolete and Unreliable Tests and Procedures - CPB 04380438

Updated

Obsolete and Unreliable Tests and Procedures - CPB 0438

0438

Updated

Seat Lifts and Patient Lifts - CPB 04590459

Updated

Seat Lifts and Patient Lifts - CPB 0459

0459

Updated

Upper Limb Prostheses - CPB 03990399

Updated

Upper Limb Prostheses - CPB 0399

0399

Updated

Urinary Incontinence - CPB 02230223

Updated

Urinary Incontinence - CPB 0223

0223

Updated

Vitiligo - CPB 04220422

Updated

Vitiligo - CPB 0422

0422

Jul 16, 2026

Aetna

Updated

Biofeedback - CPB 01320132

Updated

Biofeedback - CPB 0132

0132

Updated

Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments- CPB 04470447

Updated

Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments- CPB 0447

0447

Updated

Foot Orthotics - CPB 04510451

Updated

Foot Orthotics - CPB 0451

0451

Updated

Hematopoietic Colony-Stimulating Factors (CSFs) - CPB 00550055

Updated

Hematopoietic Colony-Stimulating Factors (CSFs) - CPB 0055

0055

Updated

Infertility - CPB 03270327

Updated

Infertility - CPB 0327

0327

Updated

Obsolete and Unreliable Tests and Procedures - CPB 04380438

Updated

Obsolete and Unreliable Tests and Procedures - CPB 0438

0438

Updated

Seat Lifts and Patient Lifts - CPB 04590459

Updated

Seat Lifts and Patient Lifts - CPB 0459

0459

Updated

Upper Limb Prostheses - CPB 03990399

Updated

Upper Limb Prostheses - CPB 0399

0399

Updated

Urinary Incontinence - CPB 02230223

Updated

Urinary Incontinence - CPB 0223

0223

Updated

Vitiligo - CPB 04220422

Updated

Vitiligo - CPB 0422

0422

Jul 15, 2026

Aetna

Updated

Cold Laser and High-Power Laser Therapies - CPB 03630363

Updated

Cold Laser and High-Power Laser Therapies - CPB 0363

0363

Updated

Laser Treatment for Psoriasis and Other Selected Skin Conditions - CPB 05770577

Updated

Laser Treatment for Psoriasis and Other Selected Skin Conditions - CPB 0577

0577

Updated

Somatostatin Analogs - CPB 06930693

Updated

Somatostatin Analogs - CPB 0693

0693

Anthem Blue Cross Blue Shield Missouri

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield Ohio

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of California

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Colorado

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Connecticut

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Georgia

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Indiana

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Maine

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of New York

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield Nevada

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield New Hampshire

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield Virginia

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield Wisconsin

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem BlueCross BlueShield Kentucky

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Blue Cross Blue Shield Oklahoma

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross Medicare Advantage

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of Illinois

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of Montana

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of New Mexico

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of Texas

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Cigna

New

Clomiphene Benefit Exclusions Overrides - (BEO002)BEO002

New

Clomiphene Benefit Exclusions Overrides - (BEO002)

BEO002

New

Infertility - Chorionic Gonadotropins - (IP0804)IP0804

New

Infertility - Chorionic Gonadotropins - (IP0804)

IP0804

New

Infertility - Follitropins - (IP0800)IP0800

New

Infertility - Follitropins - (IP0800)

IP0800

New

Infertility - Leuprolide Acetate for Injection - (IP0803)IP0803

New

Infertility - Leuprolide Acetate for Injection - (IP0803)

IP0803

New

Infertility - Menotropins for Injection - (IP0801)IP0801

New

Infertility - Menotropins for Injection - (IP0801)

IP0801

New

Lupus – Saphnelo Subcutaneous for Individual and Family Plans - (IP0810)IP0810

New

Lupus – Saphnelo Subcutaneous for Individual and Family Plans - (IP0810)

IP0810

New

Non-Infertility - Progesterone (Vaginal) Benefit Exclusions Override Policy for Employer Plans - (BEO003)BEO003

New

Non-Infertility - Progesterone (Vaginal) Benefit Exclusions Override Policy for Employer Plans - (BEO003)

BEO003

New

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage Drug List - (ST007)ST007

New

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage Drug List - (ST007)

ST007

New

Phosphodiesterase Type 5 Inhibitors - Vybrique for Employer Plans - (IP0809)IP0809

New

Phosphodiesterase Type 5 Inhibitors - Vybrique for Employer Plans - (IP0809)

IP0809

Updated

Antiseizure Medication – Vigabatrin - (IP0049)IP0049

Updated

Antiseizure Medication – Vigabatrin - (IP0049)

IP0049

Updated

Athletic Pubalgia Surgery - (0522)0522

Updated

Athletic Pubalgia Surgery - (0522)

0522

Updated

Bariatric Surgery and Procedures - (0051)0051

Updated

Bariatric Surgery and Procedures - (0051)

0051

Updated

Brands with Bioequivalent Generics - (IP0011)IP0011

Updated

Brands with Bioequivalent Generics - (IP0011)

IP0011

Updated

Cardiac Omnibus Codes - (0574)0574

Updated

Cardiac Omnibus Codes - (0574)

0574

Updated

Cardiology – Myqorzo for Individual and Family Plans - (IP0791)IP0791

Updated

Cardiology – Myqorzo for Individual and Family Plans - (IP0791)

IP0791

Updated

Cardiology – Tryvio - (IP0713)IP0713

Updated

Cardiology – Tryvio - (IP0713)

IP0713

Updated

Cardioverter-Defibrillator Devices - (0431)0431

Updated

Cardioverter-Defibrillator Devices - (0431)

0431

Updated

Category III Current Procedural Terminology (CPT®) Codes - (0558)0558

Updated

Category III Current Procedural Terminology (CPT®) Codes - (0558)

0558

Updated

Cognitive Rehabilitation - (CPG270)CPG270

Updated

Cognitive Rehabilitation - (CPG270)

CPG270

Updated

Contraceptives - (IP0036)IP0036

Updated

Contraceptives - (IP0036)

IP0036

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Alyftrek - (IP0723)IP0723

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Alyftrek - (IP0723)

IP0723

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Trikafta - (IP0434)IP0434

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Trikafta - (IP0434)

IP0434

Updated

Cystic Fibrosis – Pulmozyme - (IP0483)IP0483

Updated

Cystic Fibrosis – Pulmozyme - (IP0483)

IP0483

Updated

Diaphragmatic/Phrenic Nerve Stimulation - (0391)0391

Updated

Diaphragmatic/Phrenic Nerve Stimulation - (0391)

0391

Updated

Drugs Requiring Medical Necessity Review for Employer Plans - (1602)1602

Updated

Drugs Requiring Medical Necessity Review for Employer Plans - (1602)

1602

Updated

Duplex Scan of Extracranial Arteries - (0542)0542

Updated

Duplex Scan of Extracranial Arteries - (0542)

0542

Updated

Enzyme Replacement Therapy – Elaprase - (IP0444)IP0444

Updated

Enzyme Replacement Therapy – Elaprase - (IP0444)

IP0444

Updated

Erectile Dysfunction Agents Drug Quantity Management Policy – Per Days - (DQM017)DQM017

Updated

Erectile Dysfunction Agents Drug Quantity Management Policy – Per Days - (DQM017)

DQM017

Updated

Erythropoiesis-Stimulating Agents – Mircera - (IP0297)IP0297

Updated

Erythropoiesis-Stimulating Agents – Mircera - (IP0297)

IP0297

Updated

Excimer Laser, Dermabrasion and Chemical Peels for Dermatologic Conditions - (0505)0505

Updated

Excimer Laser, Dermabrasion and Chemical Peels for Dermatologic Conditions - (0505)

0505

Updated

Fetal Surgery - (0175)0175

Updated

Fetal Surgery - (0175)

0175

Updated

Gaucher Disease - Substrate Reduction Therapy - Cerdelga- (IP0441)IP0441

Updated

Gaucher Disease - Substrate Reduction Therapy - Cerdelga- (IP0441)

IP0441

Updated

Gaucher Disease – Substrate Reduction Therapy – Miglustat - (IP0446)IP0446

Updated

Gaucher Disease – Substrate Reduction Therapy – Miglustat - (IP0446)

IP0446

Updated

Genetic Testing for Hereditary and Multifactorial Conditions - (0052)0052

Updated

Genetic Testing for Hereditary and Multifactorial Conditions - (0052)

0052

Updated

Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514)0514

Updated

Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514)

0514

Updated

Gonadotropin-Releasing Hormone Agonists – Lupron Depot - (IP0109)IP0109

Updated

Gonadotropin-Releasing Hormone Agonists – Lupron Depot - (IP0109)

IP0109

Updated

Growth Disorders – Ngenla Prior Authorization Policy - (IP0577)IP0577

Updated

Growth Disorders – Ngenla Prior Authorization Policy - (IP0577)

IP0577

Updated

Growth Disorders – Skytrofa Prior Authorization Policy - (IP0375)IP0375

Updated

Growth Disorders – Skytrofa Prior Authorization Policy - (IP0375)

IP0375

Updated

Growth Disorders – Sogroya Prior Authorization Policy - (IP0576)IP0576

Updated

Growth Disorders – Sogroya Prior Authorization Policy - (IP0576)

IP0576

Updated

Head and Neck Ultrasound - (0549)0549

Updated

Head and Neck Ultrasound - (0549)

0549

Updated

Human Chorionic Gonadotropin (hCG) for Non-Fertility Use - (IP0327)IP0327

Updated

Human Chorionic Gonadotropin (hCG) for Non-Fertility Use - (IP0327)

IP0327

Updated

Hypoparathyroidism - Yorvipath - (IP0712)IP0712

Updated

Hypoparathyroidism - Yorvipath - (IP0712)

IP0712

Updated

Hypoparathyroidism – Natpara - (IP0177)IP0177

Updated

Hypoparathyroidism – Natpara - (IP0177)

IP0177

Updated

Immunologicals – Cinqair - (IP0423)IP0423

Updated

Immunologicals – Cinqair - (IP0423)

IP0423

Updated

Immunologicals – Fasenra - (IP0421)IP0421

Updated

Immunologicals – Fasenra - (IP0421)

IP0421

Updated

Immunologicals – Nucala - (IP0422)IP0422

Updated

Immunologicals – Nucala - (IP0422)

IP0422

Updated

Immunologicals – Xolair - (IP0487)IP0487

Updated

Immunologicals – Xolair - (IP0487)

IP0487

Updated

Infectious Disease – Impavido - (IP0210)IP0210

Updated

Infectious Disease – Impavido - (IP0210)

IP0210

Updated

Infectious Disease – Livtencity - (IP0394)IP0394

Updated

Infectious Disease – Livtencity - (IP0394)

IP0394

Updated

Infertility-Gondadotropin-Releasing Hormone (GnRH) Antagonists - (IP0333)IP0333

Updated

Infertility-Gondadotropin-Releasing Hormone (GnRH) Antagonists - (IP0333)

IP0333

Updated

Lupus - Saphnelo - (IP0280)IP0280

Updated

Lupus - Saphnelo - (IP0280)

IP0280

Updated

Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403)0403

Updated

Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403)

0403

Updated

Metabolic Disorders - Imcivree - (IP0104)IP0104

Updated

Metabolic Disorders - Imcivree - (IP0104)

IP0104

Updated

Migraine – Zavzpret - (IP0573)IP0573

Updated

Migraine – Zavzpret - (IP0573)

IP0573

Updated

Molecular and Proteomic Diagnostic Testing for Hematology and Oncology Indications - (0520)0520

Updated

Molecular and Proteomic Diagnostic Testing for Hematology and Oncology Indications - (0520)

0520

Updated

Muscular Dystrophy – Exondys 51 - (IP0135)IP0135

Updated

Muscular Dystrophy – Exondys 51 - (IP0135)

IP0135

Updated

Nephrology - Voyxact - (IP0788)IP0788

Updated

Nephrology - Voyxact - (IP0788)

IP0788

Updated

Nephrology – Filspari- (IP0565)IP0565

Updated

Nephrology – Filspari- (IP0565)

IP0565

Updated

Nephrology – Korsuv - (IP0436)IP0436

Updated

Nephrology – Korsuv - (IP0436)

IP0436

Updated

Neurology – Brineura - (IP0175)IP0175

Updated

Neurology – Brineura - (IP0175)

IP0175

Updated

Neurology – Rystiggo - (IP0575)IP0575

Updated

Neurology – Rystiggo - (IP0575)

IP0575

Updated

Oncology (Oral – Anaplastic Lymphoma Kinase [ALK]-Positive Agent) – Xalkori Drug Quantity Management Policy – Per Days - (DQM026)DQM026

Updated

Oncology (Oral – Anaplastic Lymphoma Kinase [ALK]-Positive Agent) – Xalkori Drug Quantity Management Policy – Per Days - (DQM026)

DQM026

Updated

Ophthalmology - Vascular Endothelial Growth Factor Inhbitors - Vabysmo - (IP0542)IP0542

Updated

Ophthalmology - Vascular Endothelial Growth Factor Inhbitors - Vabysmo - (IP0542)

IP0542

Updated

Ophthalmology – Oxervate - (IP0302)IP0302

Updated

Ophthalmology – Oxervate - (IP0302)

IP0302

Updated

Ophthalmology – Qlosi - (IP0738)IP0738

Updated

Ophthalmology – Qlosi - (IP0738)

IP0738

Updated

Opioid Therapy - Employer Group Benefit Plans - (IP0561)IP0561

Updated

Opioid Therapy - Employer Group Benefit Plans - (IP0561)

IP0561

Updated

Opioid Therapy - Individual and Family Plans - (IP0562)IP0562

Updated

Opioid Therapy - Individual and Family Plans - (IP0562)

IP0562

Updated

Otoplasty and External Ear Reconstruction - (0335)0335

Updated

Otoplasty and External Ear Reconstruction - (0335)

0335

Updated

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage/Legacy Drug Lists - (ST002)ST002

Updated

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage/Legacy Drug Lists - (ST002)

ST002

Updated

Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111)CPG111

Updated

Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111)

CPG111

Updated

Pharmacogenetic Testing - (0500)0500

Updated

Pharmacogenetic Testing - (0500)

0500

Updated

Pharmacy and Medical Prior Authorization - (1407)1407

Updated

Pharmacy and Medical Prior Authorization - (1407)

1407

Updated

Phosphodiesterase Type 5 Inhibitors - Non-Erectile Dysfunction Benefit Exclusion Override Policy for Employer Plans - (BEO001)BEO001

Updated

Phosphodiesterase Type 5 Inhibitors - Non-Erectile Dysfunction Benefit Exclusion Override Policy for Employer Plans - (BEO001)

BEO001

Updated

Phosphodiesterase Type 5 Inhibitors - Sildenafil (Viagra®, Vybrique™) for Individual and Family Plans - (IP0098)IP0098

Updated

Phosphodiesterase Type 5 Inhibitors - Sildenafil (Viagra®, Vybrique™) for Individual and Family Plans - (IP0098)

IP0098

Updated

Pompe Disease – Enzyme Replacement Therapy – Lumizyme - (IP0440)IP0440

Updated

Pompe Disease – Enzyme Replacement Therapy – Lumizyme - (IP0440)

IP0440

Updated

Pompe Disease – Enzyme Replacement Therapy – Nexviazyme - (IP0279)IP0279

Updated

Pompe Disease – Enzyme Replacement Therapy – Nexviazyme - (IP0279)

IP0279

Updated

Pompe Disease – Enzyme Replacement Therapy – Pombiliti - (IP0591)IP0591

Updated

Pompe Disease – Enzyme Replacement Therapy – Pombiliti - (IP0591)

IP0591

Updated

Pompe Disease – Enzyme Stabilization Therapy – Opfolda - (IP0598)IP0598

Updated

Pompe Disease – Enzyme Stabilization Therapy – Opfolda - (IP0598)

IP0598

Updated

Progesterone (Vaginal) for Individual and Family Plans - (IP0091)IP0091

Updated

Progesterone (Vaginal) for Individual and Family Plans - (IP0091)

IP0091

Updated

Psychiatry - Zulresso - (IP0270)IP0270

Updated

Psychiatry - Zulresso - (IP0270)

IP0270

Updated

Scrotal Ultrasound - (0548)0548

Updated

Scrotal Ultrasound - (0548)

0548

Updated

Thrombocytopenia – Doptelet - (IP0152)IP0152

Updated

Thrombocytopenia – Doptelet - (IP0152)

IP0152

Updated

Thrombocytopenia – Eltrombopag Products - (IP0153)IP0153

Updated

Thrombocytopenia – Eltrombopag Products - (IP0153)

IP0153

Updated

Thrombocytopenia – Nplate - (IP0155)IP0155

Updated

Thrombocytopenia – Nplate - (IP0155)

IP0155

Updated

Thrombocytopenia – Tavalisse - (IP0154)IP0154

Updated

Thrombocytopenia – Tavalisse - (IP0154)

IP0154

Updated

Thrombocytopenia – Wayrilz - (IP0774)IP0774

Updated

Thrombocytopenia – Wayrilz - (IP0774)

IP0774

Updated

Ultrasound Guidance for Trigger Point Injections - (0139)0139

Updated

Ultrasound Guidance for Trigger Point Injections - (0139)

0139

Updated

Vesicular Monoamine Transporter Inhibitors – Austedo - (IP0079)IP0079

Updated

Vesicular Monoamine Transporter Inhibitors – Austedo - (IP0079)

IP0079

Updated

Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza Products - (IP0080)IP0080

Updated

Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza Products - (IP0080)

IP0080

Updated

Vijoice - (IP0481)IP0481

Updated

Vijoice - (IP0481)

IP0481

Updated

Wakefulness-Promoting Agents – Oxybate Products - (IP0103)IP0103

Updated

Wakefulness-Promoting Agents – Oxybate Products - (IP0103)

IP0103

Florida Blue

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions02-65000-19

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions

02-65000-19

Updated

Aqueous Shunts and Stents for Glaucoma01-92000-24

Updated

Aqueous Shunts and Stents for Glaucoma

01-92000-24

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion09-J3000-80

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion

09-J3000-80

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid02-10000-11

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid

02-10000-11

Updated

Biofeedback01-90900-01

Updated

Biofeedback

01-90900-01

Updated

Brentuximab (Adcetris) Injection09-J1000-53

Updated

Brentuximab (Adcetris) Injection

09-J1000-53

Updated

Carfilzomib (Kyprolis) Injection09-J1000-81

Updated

Carfilzomib (Kyprolis) Injection

09-J1000-81

Updated

Computed Tomography (CT) Head and Brain04-70450-18

Updated

Computed Tomography (CT) Head and Brain

04-70450-18

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial04-70450-19

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial

04-70450-19

Updated

Computed Tomography (CT) Thorax (Chest)04-70450-21

Updated

Computed Tomography (CT) Thorax (Chest)

04-70450-21

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation04-70450-20

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation

04-70450-20

Updated

Computer-Assisted Navigation for Orthopedic Procedures02-20000-30

Updated

Computer-Assisted Navigation for Orthopedic Procedures

02-20000-30

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection09-J2000-49

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection

09-J2000-49

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion09-J5000-19

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion

09-J5000-19

Updated

Deep Brain Stimulation and Responsive Neurostimulation02-61000-24

Updated

Deep Brain Stimulation and Responsive Neurostimulation

02-61000-24

Updated

Denosumab (Prolia, Xgeva) Injection09-J1000-25

Updated

Denosumab (Prolia, Xgeva) Injection

09-J1000-25

Updated

Dinutuximab (Unituxin)09-J2000-42

Updated

Dinutuximab (Unituxin)

09-J2000-42

Updated

Drug Waste Reduction09-J5000-54

Updated

Drug Waste Reduction

09-J5000-54

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection09-J4000-18

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection

09-J4000-18

Updated

Elotuzumab (Empliciti) Injection09-J2000-50

Updated

Elotuzumab (Empliciti) Injection

09-J2000-50

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection09-J4000-64

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection

09-J4000-64

Updated

Eptinezumab-jjmr (Vyepti)09-J3000-68

Updated

Eptinezumab-jjmr (Vyepti)

09-J3000-68

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors01-99000-03

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors

01-99000-03

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)09-J3000-58

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)

09-J3000-58

Updated

Furosemide (Furoscix) subcutaneous infusion09-J4000-43

Updated

Furosemide (Furoscix) subcutaneous infusion

09-J4000-43

Updated

Ganaxolone (Ztalmy) Oral Suspension09-J4000-39

Updated

Ganaxolone (Ztalmy) Oral Suspension

09-J4000-39

Updated

Heart and Lung Transplant02-33000-24

Updated

Heart and Lung Transplant

02-33000-24

Updated

High Resolution Anoscopy02-46000-01

Updated

High Resolution Anoscopy

02-46000-01

Updated

Hydrocortisone (Khindivi) oral solution09-J5000-22

Updated

Hydrocortisone (Khindivi) oral solution

09-J5000-22

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids02-69000-06

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids

02-69000-06

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease09-J0000-41

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease

09-J0000-41

Updated

Investigational Services09-A0000-03

Updated

Investigational Services

09-A0000-03

Updated

Isatuximab-irfc (Sarclisa) Infusion09-J3000-67

Updated

Isatuximab-irfc (Sarclisa) Infusion

09-J3000-67

Updated

Lanreotide (Somatuline Depot) Injection09-J1000-20

Updated

Lanreotide (Somatuline Depot) Injection

09-J1000-20

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids02-56000-30

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids

02-56000-30

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet09-J5000-23

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet

09-J5000-23

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion09-J5000-27

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion

09-J5000-27

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion09-J4000-83

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion

09-J4000-83

Updated

Manipulation Under Anesthesia02-20000-34

Updated

Manipulation Under Anesthesia

02-20000-34

Updated

Naxitamab-gqgk (Danyelza) Injection09-J3000-92

Updated

Naxitamab-gqgk (Danyelza) Injection

09-J3000-92

Updated

New-To-Market Program for Provider-Administered Medications09-J4000-30

Updated

New-To-Market Program for Provider-Administered Medications

09-J4000-30

Updated

Nipocalimab-aahu (Imaavy)09-J5000-25

Updated

Nipocalimab-aahu (Imaavy)

09-J5000-25

Updated

Non-Covered Services09-A0000-00

Updated

Non-Covered Services

09-A0000-00

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA03-59000-18

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA

03-59000-18

Updated

Omalizumab (Xolair, Omlyclo)09-J0000-44

Updated

Omalizumab (Xolair, Omlyclo)

09-J0000-44

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)09-J3000-30

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)

09-J3000-30

Updated

Oral Therapy for Gaucher and Pompe Disease09-J0000-76

Updated

Oral Therapy for Gaucher and Pompe Disease

09-J0000-76

Updated

Pasireotide (Signifor Signifor LAR) Injection09-J1000-94

Updated

Pasireotide (Signifor Signifor LAR) Injection

09-J1000-94

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)09-J3000-69

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)

09-J3000-69

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)02-10000-16

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)

02-10000-16

Updated

Sacral Nerve Neuromodulation/Stimulation02-61000-23

Updated

Sacral Nerve Neuromodulation/Stimulation

02-61000-23

Updated

Surgical Treatment of Occipital Neuralgia and Headache02-20000-41

Updated

Surgical Treatment of Occipital Neuralgia and Headache

02-20000-41

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion09-J3000-81

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion

09-J3000-81

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection09-J4000-63

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection

09-J4000-63

Updated

Teclistamab (Tecvayli) Injection09-J4000-46

Updated

Teclistamab (Tecvayli) Injection

09-J4000-46

Updated

Tolvaptan (Jynarque)09-J3000-09

Updated

Tolvaptan (Jynarque)

09-J3000-09

Updated

Total Body Plethysmography01-94010-09

Updated

Total Body Plethysmography

01-94010-09

Updated

Trigger Point Injections02-20000-28

Updated

Trigger Point Injections

02-20000-28

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization09-J1000-78

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization

09-J1000-78

Updated

Viscocanalostomy and Canaloplasty02-65000-18

Updated

Viscocanalostomy and Canaloplasty

02-65000-18

Florida Blue Medicare

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions02-65000-19

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions

02-65000-19

Updated

Aqueous Shunts and Stents for Glaucoma01-92000-24

Updated

Aqueous Shunts and Stents for Glaucoma

01-92000-24

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion09-J3000-80

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion

09-J3000-80

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid02-10000-11

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid

02-10000-11

Updated

Biofeedback01-90900-01

Updated

Biofeedback

01-90900-01

Updated

Brentuximab (Adcetris) Injection09-J1000-53

Updated

Brentuximab (Adcetris) Injection

09-J1000-53

Updated

Carfilzomib (Kyprolis) Injection09-J1000-81

Updated

Carfilzomib (Kyprolis) Injection

09-J1000-81

Updated

Computed Tomography (CT) Head and Brain04-70450-18

Updated

Computed Tomography (CT) Head and Brain

04-70450-18

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial04-70450-19

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial

04-70450-19

Updated

Computed Tomography (CT) Thorax (Chest)04-70450-21

Updated

Computed Tomography (CT) Thorax (Chest)

04-70450-21

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation04-70450-20

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation

04-70450-20

Updated

Computer-Assisted Navigation for Orthopedic Procedures02-20000-30

Updated

Computer-Assisted Navigation for Orthopedic Procedures

02-20000-30

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection09-J2000-49

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection

09-J2000-49

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion09-J5000-19

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion

09-J5000-19

Updated

Deep Brain Stimulation and Responsive Neurostimulation02-61000-24

Updated

Deep Brain Stimulation and Responsive Neurostimulation

02-61000-24

Updated

Denosumab (Prolia, Xgeva) Injection09-J1000-25

Updated

Denosumab (Prolia, Xgeva) Injection

09-J1000-25

Updated

Dinutuximab (Unituxin)09-J2000-42

Updated

Dinutuximab (Unituxin)

09-J2000-42

Updated

Drug Waste Reduction09-J5000-54

Updated

Drug Waste Reduction

09-J5000-54

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection09-J4000-18

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection

09-J4000-18

Updated

Elotuzumab (Empliciti) Injection09-J2000-50

Updated

Elotuzumab (Empliciti) Injection

09-J2000-50

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection09-J4000-64

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection

09-J4000-64

Updated

Eptinezumab-jjmr (Vyepti)09-J3000-68

Updated

Eptinezumab-jjmr (Vyepti)

09-J3000-68

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors01-99000-03

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors

01-99000-03

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)09-J3000-58

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)

09-J3000-58

Updated

Furosemide (Furoscix) subcutaneous infusion09-J4000-43

Updated

Furosemide (Furoscix) subcutaneous infusion

09-J4000-43

Updated

Ganaxolone (Ztalmy) Oral Suspension09-J4000-39

Updated

Ganaxolone (Ztalmy) Oral Suspension

09-J4000-39

Updated

Heart and Lung Transplant02-33000-24

Updated

Heart and Lung Transplant

02-33000-24

Updated

High Resolution Anoscopy02-46000-01

Updated

High Resolution Anoscopy

02-46000-01

Updated

Hydrocortisone (Khindivi) oral solution09-J5000-22

Updated

Hydrocortisone (Khindivi) oral solution

09-J5000-22

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids02-69000-06

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids

02-69000-06

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease09-J0000-41

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease

09-J0000-41

Updated

Investigational Services09-A0000-03

Updated

Investigational Services

09-A0000-03

Updated

Isatuximab-irfc (Sarclisa) Infusion09-J3000-67

Updated

Isatuximab-irfc (Sarclisa) Infusion

09-J3000-67

Updated

Lanreotide (Somatuline Depot) Injection09-J1000-20

Updated

Lanreotide (Somatuline Depot) Injection

09-J1000-20

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids02-56000-30

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids

02-56000-30

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet09-J5000-23

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet

09-J5000-23

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion09-J5000-27

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion

09-J5000-27

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion09-J4000-83

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion

09-J4000-83

Updated

Manipulation Under Anesthesia02-20000-34

Updated

Manipulation Under Anesthesia

02-20000-34

Updated

Naxitamab-gqgk (Danyelza) Injection09-J3000-92

Updated

Naxitamab-gqgk (Danyelza) Injection

09-J3000-92

Updated

New-To-Market Program for Provider-Administered Medications09-J4000-30

Updated

New-To-Market Program for Provider-Administered Medications

09-J4000-30

Updated

Nipocalimab-aahu (Imaavy)09-J5000-25

Updated

Nipocalimab-aahu (Imaavy)

09-J5000-25

Updated

Non-Covered Services09-A0000-00

Updated

Non-Covered Services

09-A0000-00

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA03-59000-18

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA

03-59000-18

Updated

Omalizumab (Xolair, Omlyclo)09-J0000-44

Updated

Omalizumab (Xolair, Omlyclo)

09-J0000-44

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)09-J3000-30

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)

09-J3000-30

Updated

Oral Therapy for Gaucher and Pompe Disease09-J0000-76

Updated

Oral Therapy for Gaucher and Pompe Disease

09-J0000-76

Updated

Pasireotide (Signifor Signifor LAR) Injection09-J1000-94

Updated

Pasireotide (Signifor Signifor LAR) Injection

09-J1000-94

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)09-J3000-69

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)

09-J3000-69

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)02-10000-16

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)

02-10000-16

Updated

Sacral Nerve Neuromodulation/Stimulation02-61000-23

Updated

Sacral Nerve Neuromodulation/Stimulation

02-61000-23

Updated

Surgical Treatment of Occipital Neuralgia and Headache02-20000-41

Updated

Surgical Treatment of Occipital Neuralgia and Headache

02-20000-41

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion09-J3000-81

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion

09-J3000-81

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection09-J4000-63

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection

09-J4000-63

Updated

Teclistamab (Tecvayli) Injection09-J4000-46

Updated

Teclistamab (Tecvayli) Injection

09-J4000-46

Updated

Tolvaptan (Jynarque)09-J3000-09

Updated

Tolvaptan (Jynarque)

09-J3000-09

Updated

Total Body Plethysmography01-94010-09

Updated

Total Body Plethysmography

01-94010-09

Updated

Trigger Point Injections02-20000-28

Updated

Trigger Point Injections

02-20000-28

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization09-J1000-78

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization

09-J1000-78

Updated

Viscocanalostomy and Canaloplasty02-65000-18

Updated

Viscocanalostomy and Canaloplasty

02-65000-18

Humana

New

Injections for Chronic Pain Conditions - MEDICAID - KENTUCKYHUM-2137-001

New

Injections for Chronic Pain Conditions - MEDICAID - KENTUCKY

HUM-2137-001

Jul 15, 2026

Aetna

Updated

Cold Laser and High-Power Laser Therapies - CPB 03630363

Updated

Cold Laser and High-Power Laser Therapies - CPB 0363

0363

Updated

Laser Treatment for Psoriasis and Other Selected Skin Conditions - CPB 05770577

Updated

Laser Treatment for Psoriasis and Other Selected Skin Conditions - CPB 0577

0577

Updated

Somatostatin Analogs - CPB 06930693

Updated

Somatostatin Analogs - CPB 0693

0693

Anthem Blue Cross Blue Shield Missouri

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield Ohio

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of California

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Colorado

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Connecticut

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Georgia

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Indiana

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of Maine

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross Blue Shield of New York

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield Nevada

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield New Hampshire

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield Virginia

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem Blue Cross and Blue Shield Wisconsin

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Anthem BlueCross BlueShield Kentucky

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic SyndromeMED.00164

New

MED.00164 Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome

MED.00164

Updated

ImmunoglobulinsCC-0003

Updated

Immunoglobulins

CC-0003

Blue Cross Blue Shield Oklahoma

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross Medicare Advantage

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of Illinois

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of Montana

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of New Mexico

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Blue Cross and Blue Shield of Texas

New

ObinutuzumabRX501.187

New

Obinutuzumab

RX501.187

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular DiseaseMED207.008

Updated

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

MED207.008

Cigna

New

Clomiphene Benefit Exclusions Overrides - (BEO002)BEO002

New

Clomiphene Benefit Exclusions Overrides - (BEO002)

BEO002

New

Infertility - Chorionic Gonadotropins - (IP0804)IP0804

New

Infertility - Chorionic Gonadotropins - (IP0804)

IP0804

New

Infertility - Follitropins - (IP0800)IP0800

New

Infertility - Follitropins - (IP0800)

IP0800

New

Infertility - Leuprolide Acetate for Injection - (IP0803)IP0803

New

Infertility - Leuprolide Acetate for Injection - (IP0803)

IP0803

New

Infertility - Menotropins for Injection - (IP0801)IP0801

New

Infertility - Menotropins for Injection - (IP0801)

IP0801

New

Lupus – Saphnelo Subcutaneous for Individual and Family Plans - (IP0810)IP0810

New

Lupus – Saphnelo Subcutaneous for Individual and Family Plans - (IP0810)

IP0810

New

Non-Infertility - Progesterone (Vaginal) Benefit Exclusions Override Policy for Employer Plans - (BEO003)BEO003

New

Non-Infertility - Progesterone (Vaginal) Benefit Exclusions Override Policy for Employer Plans - (BEO003)

BEO003

New

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage Drug List - (ST007)ST007

New

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage Drug List - (ST007)

ST007

New

Phosphodiesterase Type 5 Inhibitors - Vybrique for Employer Plans - (IP0809)IP0809

New

Phosphodiesterase Type 5 Inhibitors - Vybrique for Employer Plans - (IP0809)

IP0809

Updated

Antiseizure Medication – Vigabatrin - (IP0049)IP0049

Updated

Antiseizure Medication – Vigabatrin - (IP0049)

IP0049

Updated

Athletic Pubalgia Surgery - (0522)0522

Updated

Athletic Pubalgia Surgery - (0522)

0522

Updated

Bariatric Surgery and Procedures - (0051)0051

Updated

Bariatric Surgery and Procedures - (0051)

0051

Updated

Brands with Bioequivalent Generics - (IP0011)IP0011

Updated

Brands with Bioequivalent Generics - (IP0011)

IP0011

Updated

Cardiac Omnibus Codes - (0574)0574

Updated

Cardiac Omnibus Codes - (0574)

0574

Updated

Cardiology – Myqorzo for Individual and Family Plans - (IP0791)IP0791

Updated

Cardiology – Myqorzo for Individual and Family Plans - (IP0791)

IP0791

Updated

Cardiology – Tryvio - (IP0713)IP0713

Updated

Cardiology – Tryvio - (IP0713)

IP0713

Updated

Cardioverter-Defibrillator Devices - (0431)0431

Updated

Cardioverter-Defibrillator Devices - (0431)

0431

Updated

Category III Current Procedural Terminology (CPT®) Codes - (0558)0558

Updated

Category III Current Procedural Terminology (CPT®) Codes - (0558)

0558

Updated

Cognitive Rehabilitation - (CPG270)CPG270

Updated

Cognitive Rehabilitation - (CPG270)

CPG270

Updated

Contraceptives - (IP0036)IP0036

Updated

Contraceptives - (IP0036)

IP0036

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Alyftrek - (IP0723)IP0723

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Alyftrek - (IP0723)

IP0723

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Trikafta - (IP0434)IP0434

Updated

Cystic Fibrosis Transmembrane Conductance Regulator – Trikafta - (IP0434)

IP0434

Updated

Cystic Fibrosis – Pulmozyme - (IP0483)IP0483

Updated

Cystic Fibrosis – Pulmozyme - (IP0483)

IP0483

Updated

Diaphragmatic/Phrenic Nerve Stimulation - (0391)0391

Updated

Diaphragmatic/Phrenic Nerve Stimulation - (0391)

0391

Updated

Drugs Requiring Medical Necessity Review for Employer Plans - (1602)1602

Updated

Drugs Requiring Medical Necessity Review for Employer Plans - (1602)

1602

Updated

Duplex Scan of Extracranial Arteries - (0542)0542

Updated

Duplex Scan of Extracranial Arteries - (0542)

0542

Updated

Enzyme Replacement Therapy – Elaprase - (IP0444)IP0444

Updated

Enzyme Replacement Therapy – Elaprase - (IP0444)

IP0444

Updated

Erectile Dysfunction Agents Drug Quantity Management Policy – Per Days - (DQM017)DQM017

Updated

Erectile Dysfunction Agents Drug Quantity Management Policy – Per Days - (DQM017)

DQM017

Updated

Erythropoiesis-Stimulating Agents – Mircera - (IP0297)IP0297

Updated

Erythropoiesis-Stimulating Agents – Mircera - (IP0297)

IP0297

Updated

Excimer Laser, Dermabrasion and Chemical Peels for Dermatologic Conditions - (0505)0505

Updated

Excimer Laser, Dermabrasion and Chemical Peels for Dermatologic Conditions - (0505)

0505

Updated

Fetal Surgery - (0175)0175

Updated

Fetal Surgery - (0175)

0175

Updated

Gaucher Disease - Substrate Reduction Therapy - Cerdelga- (IP0441)IP0441

Updated

Gaucher Disease - Substrate Reduction Therapy - Cerdelga- (IP0441)

IP0441

Updated

Gaucher Disease – Substrate Reduction Therapy – Miglustat - (IP0446)IP0446

Updated

Gaucher Disease – Substrate Reduction Therapy – Miglustat - (IP0446)

IP0446

Updated

Genetic Testing for Hereditary and Multifactorial Conditions - (0052)0052

Updated

Genetic Testing for Hereditary and Multifactorial Conditions - (0052)

0052

Updated

Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514)0514

Updated

Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514)

0514

Updated

Gonadotropin-Releasing Hormone Agonists – Lupron Depot - (IP0109)IP0109

Updated

Gonadotropin-Releasing Hormone Agonists – Lupron Depot - (IP0109)

IP0109

Updated

Growth Disorders – Ngenla Prior Authorization Policy - (IP0577)IP0577

Updated

Growth Disorders – Ngenla Prior Authorization Policy - (IP0577)

IP0577

Updated

Growth Disorders – Skytrofa Prior Authorization Policy - (IP0375)IP0375

Updated

Growth Disorders – Skytrofa Prior Authorization Policy - (IP0375)

IP0375

Updated

Growth Disorders – Sogroya Prior Authorization Policy - (IP0576)IP0576

Updated

Growth Disorders – Sogroya Prior Authorization Policy - (IP0576)

IP0576

Updated

Head and Neck Ultrasound - (0549)0549

Updated

Head and Neck Ultrasound - (0549)

0549

Updated

Human Chorionic Gonadotropin (hCG) for Non-Fertility Use - (IP0327)IP0327

Updated

Human Chorionic Gonadotropin (hCG) for Non-Fertility Use - (IP0327)

IP0327

Updated

Hypoparathyroidism - Yorvipath - (IP0712)IP0712

Updated

Hypoparathyroidism - Yorvipath - (IP0712)

IP0712

Updated

Hypoparathyroidism – Natpara - (IP0177)IP0177

Updated

Hypoparathyroidism – Natpara - (IP0177)

IP0177

Updated

Immunologicals – Cinqair - (IP0423)IP0423

Updated

Immunologicals – Cinqair - (IP0423)

IP0423

Updated

Immunologicals – Fasenra - (IP0421)IP0421

Updated

Immunologicals – Fasenra - (IP0421)

IP0421

Updated

Immunologicals – Nucala - (IP0422)IP0422

Updated

Immunologicals – Nucala - (IP0422)

IP0422

Updated

Immunologicals – Xolair - (IP0487)IP0487

Updated

Immunologicals – Xolair - (IP0487)

IP0487

Updated

Infectious Disease – Impavido - (IP0210)IP0210

Updated

Infectious Disease – Impavido - (IP0210)

IP0210

Updated

Infectious Disease – Livtencity - (IP0394)IP0394

Updated

Infectious Disease – Livtencity - (IP0394)

IP0394

Updated

Infertility-Gondadotropin-Releasing Hormone (GnRH) Antagonists - (IP0333)IP0333

Updated

Infertility-Gondadotropin-Releasing Hormone (GnRH) Antagonists - (IP0333)

IP0333

Updated

Lupus - Saphnelo - (IP0280)IP0280

Updated

Lupus - Saphnelo - (IP0280)

IP0280

Updated

Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403)0403

Updated

Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403)

0403

Updated

Metabolic Disorders - Imcivree - (IP0104)IP0104

Updated

Metabolic Disorders - Imcivree - (IP0104)

IP0104

Updated

Migraine – Zavzpret - (IP0573)IP0573

Updated

Migraine – Zavzpret - (IP0573)

IP0573

Updated

Molecular and Proteomic Diagnostic Testing for Hematology and Oncology Indications - (0520)0520

Updated

Molecular and Proteomic Diagnostic Testing for Hematology and Oncology Indications - (0520)

0520

Updated

Muscular Dystrophy – Exondys 51 - (IP0135)IP0135

Updated

Muscular Dystrophy – Exondys 51 - (IP0135)

IP0135

Updated

Nephrology - Voyxact - (IP0788)IP0788

Updated

Nephrology - Voyxact - (IP0788)

IP0788

Updated

Nephrology – Filspari- (IP0565)IP0565

Updated

Nephrology – Filspari- (IP0565)

IP0565

Updated

Nephrology – Korsuv - (IP0436)IP0436

Updated

Nephrology – Korsuv - (IP0436)

IP0436

Updated

Neurology – Brineura - (IP0175)IP0175

Updated

Neurology – Brineura - (IP0175)

IP0175

Updated

Neurology – Rystiggo - (IP0575)IP0575

Updated

Neurology – Rystiggo - (IP0575)

IP0575

Updated

Oncology (Oral – Anaplastic Lymphoma Kinase [ALK]-Positive Agent) – Xalkori Drug Quantity Management Policy – Per Days - (DQM026)DQM026

Updated

Oncology (Oral – Anaplastic Lymphoma Kinase [ALK]-Positive Agent) – Xalkori Drug Quantity Management Policy – Per Days - (DQM026)

DQM026

Updated

Ophthalmology - Vascular Endothelial Growth Factor Inhbitors - Vabysmo - (IP0542)IP0542

Updated

Ophthalmology - Vascular Endothelial Growth Factor Inhbitors - Vabysmo - (IP0542)

IP0542

Updated

Ophthalmology – Oxervate - (IP0302)IP0302

Updated

Ophthalmology – Oxervate - (IP0302)

IP0302

Updated

Ophthalmology – Qlosi - (IP0738)IP0738

Updated

Ophthalmology – Qlosi - (IP0738)

IP0738

Updated

Opioid Therapy - Employer Group Benefit Plans - (IP0561)IP0561

Updated

Opioid Therapy - Employer Group Benefit Plans - (IP0561)

IP0561

Updated

Opioid Therapy - Individual and Family Plans - (IP0562)IP0562

Updated

Opioid Therapy - Individual and Family Plans - (IP0562)

IP0562

Updated

Otoplasty and External Ear Reconstruction - (0335)0335

Updated

Otoplasty and External Ear Reconstruction - (0335)

0335

Updated

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage/Legacy Drug Lists - (ST002)ST002

Updated

Overactive Bladder Medications Step Therapy Policy for Employer Plans: Value/Advantage/Legacy Drug Lists - (ST002)

ST002

Updated

Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111)CPG111

Updated

Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111)

CPG111

Updated

Pharmacogenetic Testing - (0500)0500

Updated

Pharmacogenetic Testing - (0500)

0500

Updated

Pharmacy and Medical Prior Authorization - (1407)1407

Updated

Pharmacy and Medical Prior Authorization - (1407)

1407

Updated

Phosphodiesterase Type 5 Inhibitors - Non-Erectile Dysfunction Benefit Exclusion Override Policy for Employer Plans - (BEO001)BEO001

Updated

Phosphodiesterase Type 5 Inhibitors - Non-Erectile Dysfunction Benefit Exclusion Override Policy for Employer Plans - (BEO001)

BEO001

Updated

Phosphodiesterase Type 5 Inhibitors - Sildenafil (Viagra®, Vybrique™) for Individual and Family Plans - (IP0098)IP0098

Updated

Phosphodiesterase Type 5 Inhibitors - Sildenafil (Viagra®, Vybrique™) for Individual and Family Plans - (IP0098)

IP0098

Updated

Pompe Disease – Enzyme Replacement Therapy – Lumizyme - (IP0440)IP0440

Updated

Pompe Disease – Enzyme Replacement Therapy – Lumizyme - (IP0440)

IP0440

Updated

Pompe Disease – Enzyme Replacement Therapy – Nexviazyme - (IP0279)IP0279

Updated

Pompe Disease – Enzyme Replacement Therapy – Nexviazyme - (IP0279)

IP0279

Updated

Pompe Disease – Enzyme Replacement Therapy – Pombiliti - (IP0591)IP0591

Updated

Pompe Disease – Enzyme Replacement Therapy – Pombiliti - (IP0591)

IP0591

Updated

Pompe Disease – Enzyme Stabilization Therapy – Opfolda - (IP0598)IP0598

Updated

Pompe Disease – Enzyme Stabilization Therapy – Opfolda - (IP0598)

IP0598

Updated

Progesterone (Vaginal) for Individual and Family Plans - (IP0091)IP0091

Updated

Progesterone (Vaginal) for Individual and Family Plans - (IP0091)

IP0091

Updated

Psychiatry - Zulresso - (IP0270)IP0270

Updated

Psychiatry - Zulresso - (IP0270)

IP0270

Updated

Scrotal Ultrasound - (0548)0548

Updated

Scrotal Ultrasound - (0548)

0548

Updated

Thrombocytopenia – Doptelet - (IP0152)IP0152

Updated

Thrombocytopenia – Doptelet - (IP0152)

IP0152

Updated

Thrombocytopenia – Eltrombopag Products - (IP0153)IP0153

Updated

Thrombocytopenia – Eltrombopag Products - (IP0153)

IP0153

Updated

Thrombocytopenia – Nplate - (IP0155)IP0155

Updated

Thrombocytopenia – Nplate - (IP0155)

IP0155

Updated

Thrombocytopenia – Tavalisse - (IP0154)IP0154

Updated

Thrombocytopenia – Tavalisse - (IP0154)

IP0154

Updated

Thrombocytopenia – Wayrilz - (IP0774)IP0774

Updated

Thrombocytopenia – Wayrilz - (IP0774)

IP0774

Updated

Ultrasound Guidance for Trigger Point Injections - (0139)0139

Updated

Ultrasound Guidance for Trigger Point Injections - (0139)

0139

Updated

Vesicular Monoamine Transporter Inhibitors – Austedo - (IP0079)IP0079

Updated

Vesicular Monoamine Transporter Inhibitors – Austedo - (IP0079)

IP0079

Updated

Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza Products - (IP0080)IP0080

Updated

Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza Products - (IP0080)

IP0080

Updated

Vijoice - (IP0481)IP0481

Updated

Vijoice - (IP0481)

IP0481

Updated

Wakefulness-Promoting Agents – Oxybate Products - (IP0103)IP0103

Updated

Wakefulness-Promoting Agents – Oxybate Products - (IP0103)

IP0103

Florida Blue

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions02-65000-19

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions

02-65000-19

Updated

Aqueous Shunts and Stents for Glaucoma01-92000-24

Updated

Aqueous Shunts and Stents for Glaucoma

01-92000-24

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion09-J3000-80

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion

09-J3000-80

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid02-10000-11

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid

02-10000-11

Updated

Biofeedback01-90900-01

Updated

Biofeedback

01-90900-01

Updated

Brentuximab (Adcetris) Injection09-J1000-53

Updated

Brentuximab (Adcetris) Injection

09-J1000-53

Updated

Carfilzomib (Kyprolis) Injection09-J1000-81

Updated

Carfilzomib (Kyprolis) Injection

09-J1000-81

Updated

Computed Tomography (CT) Head and Brain04-70450-18

Updated

Computed Tomography (CT) Head and Brain

04-70450-18

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial04-70450-19

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial

04-70450-19

Updated

Computed Tomography (CT) Thorax (Chest)04-70450-21

Updated

Computed Tomography (CT) Thorax (Chest)

04-70450-21

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation04-70450-20

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation

04-70450-20

Updated

Computer-Assisted Navigation for Orthopedic Procedures02-20000-30

Updated

Computer-Assisted Navigation for Orthopedic Procedures

02-20000-30

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection09-J2000-49

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection

09-J2000-49

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion09-J5000-19

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion

09-J5000-19

Updated

Deep Brain Stimulation and Responsive Neurostimulation02-61000-24

Updated

Deep Brain Stimulation and Responsive Neurostimulation

02-61000-24

Updated

Denosumab (Prolia, Xgeva) Injection09-J1000-25

Updated

Denosumab (Prolia, Xgeva) Injection

09-J1000-25

Updated

Dinutuximab (Unituxin)09-J2000-42

Updated

Dinutuximab (Unituxin)

09-J2000-42

Updated

Drug Waste Reduction09-J5000-54

Updated

Drug Waste Reduction

09-J5000-54

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection09-J4000-18

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection

09-J4000-18

Updated

Elotuzumab (Empliciti) Injection09-J2000-50

Updated

Elotuzumab (Empliciti) Injection

09-J2000-50

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection09-J4000-64

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection

09-J4000-64

Updated

Eptinezumab-jjmr (Vyepti)09-J3000-68

Updated

Eptinezumab-jjmr (Vyepti)

09-J3000-68

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors01-99000-03

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors

01-99000-03

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)09-J3000-58

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)

09-J3000-58

Updated

Furosemide (Furoscix) subcutaneous infusion09-J4000-43

Updated

Furosemide (Furoscix) subcutaneous infusion

09-J4000-43

Updated

Ganaxolone (Ztalmy) Oral Suspension09-J4000-39

Updated

Ganaxolone (Ztalmy) Oral Suspension

09-J4000-39

Updated

Heart and Lung Transplant02-33000-24

Updated

Heart and Lung Transplant

02-33000-24

Updated

High Resolution Anoscopy02-46000-01

Updated

High Resolution Anoscopy

02-46000-01

Updated

Hydrocortisone (Khindivi) oral solution09-J5000-22

Updated

Hydrocortisone (Khindivi) oral solution

09-J5000-22

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids02-69000-06

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids

02-69000-06

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease09-J0000-41

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease

09-J0000-41

Updated

Investigational Services09-A0000-03

Updated

Investigational Services

09-A0000-03

Updated

Isatuximab-irfc (Sarclisa) Infusion09-J3000-67

Updated

Isatuximab-irfc (Sarclisa) Infusion

09-J3000-67

Updated

Lanreotide (Somatuline Depot) Injection09-J1000-20

Updated

Lanreotide (Somatuline Depot) Injection

09-J1000-20

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids02-56000-30

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids

02-56000-30

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet09-J5000-23

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet

09-J5000-23

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion09-J5000-27

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion

09-J5000-27

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion09-J4000-83

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion

09-J4000-83

Updated

Manipulation Under Anesthesia02-20000-34

Updated

Manipulation Under Anesthesia

02-20000-34

Updated

Naxitamab-gqgk (Danyelza) Injection09-J3000-92

Updated

Naxitamab-gqgk (Danyelza) Injection

09-J3000-92

Updated

New-To-Market Program for Provider-Administered Medications09-J4000-30

Updated

New-To-Market Program for Provider-Administered Medications

09-J4000-30

Updated

Nipocalimab-aahu (Imaavy)09-J5000-25

Updated

Nipocalimab-aahu (Imaavy)

09-J5000-25

Updated

Non-Covered Services09-A0000-00

Updated

Non-Covered Services

09-A0000-00

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA03-59000-18

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA

03-59000-18

Updated

Omalizumab (Xolair, Omlyclo)09-J0000-44

Updated

Omalizumab (Xolair, Omlyclo)

09-J0000-44

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)09-J3000-30

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)

09-J3000-30

Updated

Oral Therapy for Gaucher and Pompe Disease09-J0000-76

Updated

Oral Therapy for Gaucher and Pompe Disease

09-J0000-76

Updated

Pasireotide (Signifor Signifor LAR) Injection09-J1000-94

Updated

Pasireotide (Signifor Signifor LAR) Injection

09-J1000-94

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)09-J3000-69

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)

09-J3000-69

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)02-10000-16

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)

02-10000-16

Updated

Sacral Nerve Neuromodulation/Stimulation02-61000-23

Updated

Sacral Nerve Neuromodulation/Stimulation

02-61000-23

Updated

Surgical Treatment of Occipital Neuralgia and Headache02-20000-41

Updated

Surgical Treatment of Occipital Neuralgia and Headache

02-20000-41

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion09-J3000-81

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion

09-J3000-81

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection09-J4000-63

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection

09-J4000-63

Updated

Teclistamab (Tecvayli) Injection09-J4000-46

Updated

Teclistamab (Tecvayli) Injection

09-J4000-46

Updated

Tolvaptan (Jynarque)09-J3000-09

Updated

Tolvaptan (Jynarque)

09-J3000-09

Updated

Total Body Plethysmography01-94010-09

Updated

Total Body Plethysmography

01-94010-09

Updated

Trigger Point Injections02-20000-28

Updated

Trigger Point Injections

02-20000-28

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization09-J1000-78

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization

09-J1000-78

Updated

Viscocanalostomy and Canaloplasty02-65000-18

Updated

Viscocanalostomy and Canaloplasty

02-65000-18

Florida Blue Medicare

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions02-65000-19

Updated

Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions

02-65000-19

Updated

Aqueous Shunts and Stents for Glaucoma01-92000-24

Updated

Aqueous Shunts and Stents for Glaucoma

01-92000-24

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion09-J3000-80

Updated

Belantamab Mafodotin-blmf (Blenrep) IV Infusion

09-J3000-80

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid02-10000-11

Updated

Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid

02-10000-11

Updated

Biofeedback01-90900-01

Updated

Biofeedback

01-90900-01

Updated

Brentuximab (Adcetris) Injection09-J1000-53

Updated

Brentuximab (Adcetris) Injection

09-J1000-53

Updated

Carfilzomib (Kyprolis) Injection09-J1000-81

Updated

Carfilzomib (Kyprolis) Injection

09-J1000-81

Updated

Computed Tomography (CT) Head and Brain04-70450-18

Updated

Computed Tomography (CT) Head and Brain

04-70450-18

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial04-70450-19

Updated

Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial

04-70450-19

Updated

Computed Tomography (CT) Thorax (Chest)04-70450-21

Updated

Computed Tomography (CT) Thorax (Chest)

04-70450-21

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation04-70450-20

Updated

Computed Tomography (CT) of the Neck for Soft Tissue Evaluation

04-70450-20

Updated

Computer-Assisted Navigation for Orthopedic Procedures02-20000-30

Updated

Computer-Assisted Navigation for Orthopedic Procedures

02-20000-30

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection09-J2000-49

Updated

Daratumumab (Darzalex) Infusion and Daratumumab-Hyaluronidase-fihj (Darzalex Faspro) Injection

09-J2000-49

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion09-J5000-19

Updated

Datopotamab Deruxtecan (Datroway) IV Infusion

09-J5000-19

Updated

Deep Brain Stimulation and Responsive Neurostimulation02-61000-24

Updated

Deep Brain Stimulation and Responsive Neurostimulation

02-61000-24

Updated

Denosumab (Prolia, Xgeva) Injection09-J1000-25

Updated

Denosumab (Prolia, Xgeva) Injection

09-J1000-25

Updated

Dinutuximab (Unituxin)09-J2000-42

Updated

Dinutuximab (Unituxin)

09-J2000-42

Updated

Drug Waste Reduction09-J5000-54

Updated

Drug Waste Reduction

09-J5000-54

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection09-J4000-18

Updated

Efgartigimod alfa-fcab (Vyvgart, Vyvgart Hytrulo) injection

09-J4000-18

Updated

Elotuzumab (Empliciti) Injection09-J2000-50

Updated

Elotuzumab (Empliciti) Injection

09-J2000-50

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection09-J4000-64

Updated

Elranatamab-bcmm (Elrexfio) Subcutaneous Injection

09-J4000-64

Updated

Eptinezumab-jjmr (Vyepti)09-J3000-68

Updated

Eptinezumab-jjmr (Vyepti)

09-J3000-68

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors01-99000-03

Updated

External Insulin Infusion Pumps and Continuous Glucose Monitors

01-99000-03

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)09-J3000-58

Updated

Fam-Trastuzumab Deruxtecan-nxki (Enhertu)

09-J3000-58

Updated

Furosemide (Furoscix) subcutaneous infusion09-J4000-43

Updated

Furosemide (Furoscix) subcutaneous infusion

09-J4000-43

Updated

Ganaxolone (Ztalmy) Oral Suspension09-J4000-39

Updated

Ganaxolone (Ztalmy) Oral Suspension

09-J4000-39

Updated

Heart and Lung Transplant02-33000-24

Updated

Heart and Lung Transplant

02-33000-24

Updated

High Resolution Anoscopy02-46000-01

Updated

High Resolution Anoscopy

02-46000-01

Updated

Hydrocortisone (Khindivi) oral solution09-J5000-22

Updated

Hydrocortisone (Khindivi) oral solution

09-J5000-22

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids02-69000-06

Updated

Implantable Bone-Conduction and Bone-Anchoring Hearing Aids

02-69000-06

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease09-J0000-41

Updated

Intravenous Enzyme Replacement Therapy For Gaucher Disease

09-J0000-41

Updated

Investigational Services09-A0000-03

Updated

Investigational Services

09-A0000-03

Updated

Isatuximab-irfc (Sarclisa) Infusion09-J3000-67

Updated

Isatuximab-irfc (Sarclisa) Infusion

09-J3000-67

Updated

Lanreotide (Somatuline Depot) Injection09-J1000-20

Updated

Lanreotide (Somatuline Depot) Injection

09-J1000-20

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids02-56000-30

Updated

Laparoscopic and Percutaneous Techniques for the Treatment of Uterine Fibroids

02-56000-30

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet09-J5000-23

Updated

Lenacapavir (Yeztugo) SQ Injection and Tablet

09-J5000-23

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion09-J5000-27

Updated

Linvoseltamab-gcpt (Lynozyfic) IV Infusion

09-J5000-27

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion09-J4000-83

Updated

Lovotibeglogene autotemcel (Lyfgenia) suspension for IV infusion

09-J4000-83

Updated

Manipulation Under Anesthesia02-20000-34

Updated

Manipulation Under Anesthesia

02-20000-34

Updated

Naxitamab-gqgk (Danyelza) Injection09-J3000-92

Updated

Naxitamab-gqgk (Danyelza) Injection

09-J3000-92

Updated

New-To-Market Program for Provider-Administered Medications09-J4000-30

Updated

New-To-Market Program for Provider-Administered Medications

09-J4000-30

Updated

Nipocalimab-aahu (Imaavy)09-J5000-25

Updated

Nipocalimab-aahu (Imaavy)

09-J5000-25

Updated

Non-Covered Services09-A0000-00

Updated

Non-Covered Services

09-A0000-00

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA03-59000-18

Updated

Noninvasive Prenatal Screening Using Cell-Free Fetal DNA

03-59000-18

Updated

Omalizumab (Xolair, Omlyclo)09-J0000-44

Updated

Omalizumab (Xolair, Omlyclo)

09-J0000-44

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)09-J3000-30

Updated

Onasemnogene abeparvovec (Zolgensma,Itvisma)

09-J3000-30

Updated

Oral Therapy for Gaucher and Pompe Disease09-J0000-76

Updated

Oral Therapy for Gaucher and Pompe Disease

09-J0000-76

Updated

Pasireotide (Signifor Signifor LAR) Injection09-J1000-94

Updated

Pasireotide (Signifor Signifor LAR) Injection

09-J1000-94

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)09-J3000-69

Updated

Peanut (Arachis hypogaea) Allergen Powder-dnfd (Palforzia)

09-J3000-69

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)02-10000-16

Updated

Psoralens Plus Ultraviolet A (PUVA) Therapy (Photochemotherapy)

02-10000-16

Updated

Sacral Nerve Neuromodulation/Stimulation02-61000-23

Updated

Sacral Nerve Neuromodulation/Stimulation

02-61000-23

Updated

Surgical Treatment of Occipital Neuralgia and Headache02-20000-41

Updated

Surgical Treatment of Occipital Neuralgia and Headache

02-20000-41

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion09-J3000-81

Updated

Tafasitamab-cxix (Monjuvi) IV Infusion

09-J3000-81

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection09-J4000-63

Updated

Talquetamab-tgvs (Talvey) Subcutaneous Injection

09-J4000-63

Updated

Teclistamab (Tecvayli) Injection09-J4000-46

Updated

Teclistamab (Tecvayli) Injection

09-J4000-46

Updated

Tolvaptan (Jynarque)09-J3000-09

Updated

Tolvaptan (Jynarque)

09-J3000-09

Updated

Total Body Plethysmography01-94010-09

Updated

Total Body Plethysmography

01-94010-09

Updated

Trigger Point Injections02-20000-28

Updated

Trigger Point Injections

02-20000-28

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization09-J1000-78

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization

09-J1000-78

Updated

Viscocanalostomy and Canaloplasty02-65000-18

Updated

Viscocanalostomy and Canaloplasty

02-65000-18

Humana

New

Injections for Chronic Pain Conditions - MEDICAID - KENTUCKYHUM-2137-001

New

Injections for Chronic Pain Conditions - MEDICAID - KENTUCKY

HUM-2137-001

Jul 14, 2026

Aetna

Updated

Botulinum Toxin - CPB 01130113

Updated

Botulinum Toxin - CPB 0113

0113

Updated

Glaucoma Surgery - CPB 04840484

Updated

Glaucoma Surgery - CPB 0484

0484

Updated

Inclisiran (Leqvio) - CPB 10041004

Updated

Inclisiran (Leqvio) - CPB 1004

1004

Updated

Pembrolizumab Products (Keytruda and Keytruda Qlex) - CPB 08900890

Updated

Pembrolizumab Products (Keytruda and Keytruda Qlex) - CPB 0890

0890

Jul 14, 2026

Aetna

Updated

Botulinum Toxin - CPB 01130113

Updated

Botulinum Toxin - CPB 0113

0113

Updated

Glaucoma Surgery - CPB 04840484

Updated

Glaucoma Surgery - CPB 0484

0484

Updated

Inclisiran (Leqvio) - CPB 10041004

Updated

Inclisiran (Leqvio) - CPB 1004

1004

Updated

Pembrolizumab Products (Keytruda and Keytruda Qlex) - CPB 08900890

Updated

Pembrolizumab Products (Keytruda and Keytruda Qlex) - CPB 0890

0890

Jul 13, 2026

Aetna

Updated

Adalimumab - CPB 06550655

Updated

Adalimumab - CPB 0655

0655

Updated

Atidarsagene Autotemcel (Lenmeldy) - CPB 10581058

Updated

Atidarsagene Autotemcel (Lenmeldy) - CPB 1058

1058

Updated

Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) - CPB 07950795

Updated

Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) - CPB 0795

0795

Updated

Intervertebral Disc Prostheses - CPB 05910591

Updated

Intervertebral Disc Prostheses - CPB 0591

0591

Updated

Progestins - CPB 05100510

Updated

Progestins - CPB 0510

0510

Updated

Testosterone Cypionate Injections - CPB 10141014

Updated

Testosterone Cypionate Injections - CPB 1014

1014

Jul 13, 2026

Aetna

Updated

Adalimumab - CPB 06550655

Updated

Adalimumab - CPB 0655

0655

Updated

Atidarsagene Autotemcel (Lenmeldy) - CPB 10581058

Updated

Atidarsagene Autotemcel (Lenmeldy) - CPB 1058

1058

Updated

Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) - CPB 07950795

Updated

Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) - CPB 0795

0795

Updated

Intervertebral Disc Prostheses - CPB 05910591

Updated

Intervertebral Disc Prostheses - CPB 0591

0591

Updated

Progestins - CPB 05100510

Updated

Progestins - CPB 0510

0510

Updated

Testosterone Cypionate Injections - CPB 10141014

Updated

Testosterone Cypionate Injections - CPB 1014

1014

Jul 10, 2026

Aetna

Updated

Alopecia Areata - CPB 04230423

Updated

Alopecia Areata - CPB 0423

0423

Updated

Amnioinfusion - CPB 04170417

Updated

Amnioinfusion - CPB 0417

0417

Updated

Gonadotropin-Releasing Hormone Analogs and Antagonists - CPB 05010501

Updated

Gonadotropin-Releasing Hormone Analogs and Antagonists - CPB 0501

0501

Updated

Intermittent Pneumatic Compression Devices - CPB 05000500

Updated

Intermittent Pneumatic Compression Devices - CPB 0500

0500

Updated

Metreleptin (Myalept) - CPB 08820882

Updated

Metreleptin (Myalept) - CPB 0882

0882

Updated

Pressure Reducing Support Surfaces - CPB 04300430

Updated

Pressure Reducing Support Surfaces - CPB 0430

0430

Updated

Tinnitus Treatments - CPB 04060406

Updated

Tinnitus Treatments - CPB 0406

0406

Jul 10, 2026

Aetna

Updated

Alopecia Areata - CPB 04230423

Updated

Alopecia Areata - CPB 0423

0423

Updated

Amnioinfusion - CPB 04170417

Updated

Amnioinfusion - CPB 0417

0417

Updated

Gonadotropin-Releasing Hormone Analogs and Antagonists - CPB 05010501

Updated

Gonadotropin-Releasing Hormone Analogs and Antagonists - CPB 0501

0501

Updated

Intermittent Pneumatic Compression Devices - CPB 05000500

Updated

Intermittent Pneumatic Compression Devices - CPB 0500

0500

Updated

Metreleptin (Myalept) - CPB 08820882

Updated

Metreleptin (Myalept) - CPB 0882

0882

Updated

Pressure Reducing Support Surfaces - CPB 04300430

Updated

Pressure Reducing Support Surfaces - CPB 0430

0430

Updated

Tinnitus Treatments - CPB 04060406

Updated

Tinnitus Treatments - CPB 0406

0406

Jul 9, 2026

Aetna

Updated

AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis - CPB 04140414

Updated

AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis - CPB 0414

0414

Updated

Carbogen Inhalation Therapy - CPB 04280428

Updated

Carbogen Inhalation Therapy - CPB 0428

0428

Updated

Computerized Motion Diagnostic Imaging - CPB 04320432

Updated

Computerized Motion Diagnostic Imaging - CPB 0432

0432

Updated

Fluidized Therapy (Fluidotherapy) - CPB 04500450

Updated

Fluidized Therapy (Fluidotherapy) - CPB 0450

0450

Updated

Gastrointestinal Function: Selected Tests - CPB 03960396

Updated

Gastrointestinal Function: Selected Tests - CPB 0396

0396

Updated

Pelvic Congestion Syndrome Treatments - CPB 04410441

Updated

Pelvic Congestion Syndrome Treatments - CPB 0441

0441

Updated

Pillows and Cushions - CPB 04560456

Updated

Pillows and Cushions - CPB 0456

0456

Updated

Respiratory Devices: Incentive Spirometers, Vaporizers and Intermittent Positive Pressure Breathing Machines - CPB 04790479

Updated

Respiratory Devices: Incentive Spirometers, Vaporizers and Intermittent Positive Pressure Breathing Machines - CPB 0479

0479

Updated

Testosterone Undecanoate (Aveed) Injection - CPB 05280528

Updated

Testosterone Undecanoate (Aveed) Injection - CPB 0528

0528

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular and Selected Indications - CPB 07010701

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular and Selected Indications - CPB 0701

0701

BlueCross BlueShield of Tennessee

New

Prenatal Genetic TestingCAM398

New

Prenatal Genetic Testing

CAM398

Jul 9, 2026

Aetna

Updated

AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis - CPB 04140414

Updated

AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis - CPB 0414

0414

Updated

Carbogen Inhalation Therapy - CPB 04280428

Updated

Carbogen Inhalation Therapy - CPB 0428

0428

Updated

Computerized Motion Diagnostic Imaging - CPB 04320432

Updated

Computerized Motion Diagnostic Imaging - CPB 0432

0432

Updated

Fluidized Therapy (Fluidotherapy) - CPB 04500450

Updated

Fluidized Therapy (Fluidotherapy) - CPB 0450

0450

Updated

Gastrointestinal Function: Selected Tests - CPB 03960396

Updated

Gastrointestinal Function: Selected Tests - CPB 0396

0396

Updated

Pelvic Congestion Syndrome Treatments - CPB 04410441

Updated

Pelvic Congestion Syndrome Treatments - CPB 0441

0441

Updated

Pillows and Cushions - CPB 04560456

Updated

Pillows and Cushions - CPB 0456

0456

Updated

Respiratory Devices: Incentive Spirometers, Vaporizers and Intermittent Positive Pressure Breathing Machines - CPB 04790479

Updated

Respiratory Devices: Incentive Spirometers, Vaporizers and Intermittent Positive Pressure Breathing Machines - CPB 0479

0479

Updated

Testosterone Undecanoate (Aveed) Injection - CPB 05280528

Updated

Testosterone Undecanoate (Aveed) Injection - CPB 0528

0528

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular and Selected Indications - CPB 07010701

Updated

Vascular Endothelial Growth Factor Inhibitors for Ocular and Selected Indications - CPB 0701

0701

BlueCross BlueShield of Tennessee

New

Prenatal Genetic TestingCAM398

New

Prenatal Genetic Testing

CAM398

Jul 8, 2026

Aetna

Updated

Antibody Tests for Neurologic Diseases - CPB 03400340

Updated

Antibody Tests for Neurologic Diseases - CPB 0340

0340

Updated

Carbon Dioxide Laser - CPB 04270427

Updated

Carbon Dioxide Laser - CPB 0427

0427

Updated

Etanercept - CPB 03150315

Updated

Etanercept - CPB 0315

0315

Updated

Implantable Hormone Pellets - CPB 03450345

Updated

Implantable Hormone Pellets - CPB 0345

0345

Updated

Lysosomal Storage Disorders Treatments - CPB 04420442

Updated

Lysosomal Storage Disorders Treatments - CPB 0442

0442

Updated

Vitrectomy - CPB 03930393

Updated

Vitrectomy - CPB 0393

0393

Humana

New

Craniosacral Therapy - MEDICAID - OKLAHOMAHUM-OK-2656-000

New

Craniosacral Therapy - MEDICAID - OKLAHOMA

HUM-OK-2656-000

Updated

Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMAHUM-OK-2429-002

Updated

Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMA

HUM-OK-2429-002

Jul 8, 2026

Aetna

Updated

Antibody Tests for Neurologic Diseases - CPB 03400340

Updated

Antibody Tests for Neurologic Diseases - CPB 0340

0340

Updated

Carbon Dioxide Laser - CPB 04270427

Updated

Carbon Dioxide Laser - CPB 0427

0427

Updated

Etanercept - CPB 03150315

Updated

Etanercept - CPB 0315

0315

Updated

Implantable Hormone Pellets - CPB 03450345

Updated

Implantable Hormone Pellets - CPB 0345

0345

Updated

Lysosomal Storage Disorders Treatments - CPB 04420442

Updated

Lysosomal Storage Disorders Treatments - CPB 0442

0442

Updated

Vitrectomy - CPB 03930393

Updated

Vitrectomy - CPB 0393

0393

Humana

New

Craniosacral Therapy - MEDICAID - OKLAHOMAHUM-OK-2656-000

New

Craniosacral Therapy - MEDICAID - OKLAHOMA

HUM-OK-2656-000

Updated

Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMAHUM-OK-2429-002

Updated

Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMA

HUM-OK-2429-002

Jul 7, 2026

Aetna

Updated

Ambulatory Electroencephalography - CPB 04250425

Updated

Ambulatory Electroencephalography - CPB 0425

0425

Updated

Attention Deficit/Hyperactivity Disorder - CPB 04260426

Updated

Attention Deficit/Hyperactivity Disorder - CPB 0426

0426

Updated

Nasolacrimal Duct Obstruction: Treatments - CPB 04200420

Updated

Nasolacrimal Duct Obstruction: Treatments - CPB 0420

0420

Updated

Polio Vaccine - CPB 04020402

Updated

Polio Vaccine - CPB 0402

0402

Updated

Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation - CPB 04070407

Updated

Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation - CPB 0407

0407

Jul 7, 2026

Aetna

Updated

Ambulatory Electroencephalography - CPB 04250425

Updated

Ambulatory Electroencephalography - CPB 0425

0425

Updated

Attention Deficit/Hyperactivity Disorder - CPB 04260426

Updated

Attention Deficit/Hyperactivity Disorder - CPB 0426

0426

Updated

Nasolacrimal Duct Obstruction: Treatments - CPB 04200420

Updated

Nasolacrimal Duct Obstruction: Treatments - CPB 0420

0420

Updated

Polio Vaccine - CPB 04020402

Updated

Polio Vaccine - CPB 0402

0402

Updated

Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation - CPB 04070407

Updated

Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation - CPB 0407

0407

Jul 6, 2026

Aetna

Updated

Ethanol Injection for Thyroid Lesions - CPB 03950395

Updated

Ethanol Injection for Thyroid Lesions - CPB 0395

0395

Updated

Hepatitis B Vaccine - CPB 04100410

Updated

Hepatitis B Vaccine - CPB 0410

0410

Updated

Knee Ligament Arthrometer Testing - CPB 03970397

Updated

Knee Ligament Arthrometer Testing - CPB 0397

0397

Updated

Macular / Foveal Translocation - CPB 04090409

Updated

Macular / Foveal Translocation - CPB 0409

0409

Updated

Optic Nerve Decompression Surgery - CPB 04150415

Updated

Optic Nerve Decompression Surgery - CPB 0415

0415

Updated

Selective Peripheral Denervation (Bertrand Procedure) - CPB 04010401

Updated

Selective Peripheral Denervation (Bertrand Procedure) - CPB 0401

0401

Jul 6, 2026

Aetna

Updated

Ethanol Injection for Thyroid Lesions - CPB 03950395

Updated

Ethanol Injection for Thyroid Lesions - CPB 0395

0395

Updated

Hepatitis B Vaccine - CPB 04100410

Updated

Hepatitis B Vaccine - CPB 0410

0410

Updated

Knee Ligament Arthrometer Testing - CPB 03970397

Updated

Knee Ligament Arthrometer Testing - CPB 0397

0397

Updated

Macular / Foveal Translocation - CPB 04090409

Updated

Macular / Foveal Translocation - CPB 0409

0409

Updated

Optic Nerve Decompression Surgery - CPB 04150415

Updated

Optic Nerve Decompression Surgery - CPB 0415

0415

Updated

Selective Peripheral Denervation (Bertrand Procedure) - CPB 04010401

Updated

Selective Peripheral Denervation (Bertrand Procedure) - CPB 0401

0401

Jul 5, 2026

Humana

Updated

Irreversible Electroporation - Medicare AdvantageHUM-1268-004

Updated

Irreversible Electroporation - Medicare Advantage

HUM-1268-004

Jul 5, 2026

Humana

Updated

Irreversible Electroporation - Medicare AdvantageHUM-1268-004

Updated

Irreversible Electroporation - Medicare Advantage

HUM-1268-004

Jul 2, 2026

Aetna

Updated

Coblation - CPB 04750475

Updated

Coblation - CPB 0475

0475

Updated

Edaravone Injection - CPB 09180918

Updated

Edaravone Injection - CPB 0918

0918

Updated

Hematopoietic Cell Transplantation for Hodgkin's Disease - CPB 04950495

Updated

Hematopoietic Cell Transplantation for Hodgkin's Disease - CPB 0495

0495

Updated

Meniere's Disease Surgery - CPB 05140514

Updated

Meniere's Disease Surgery - CPB 0514

0514

Updated

Necitumumab (Portrazza) - CPB 08980898

Updated

Necitumumab (Portrazza) - CPB 0898

0898

Updated

Nitric Oxide, Inhalational (INO) - CPB 05180518

Updated

Nitric Oxide, Inhalational (INO) - CPB 0518

0518

Updated

Standing Frames, Tables, and Transfer Boards - CPB 04810481

Updated

Standing Frames, Tables, and Transfer Boards - CPB 0481

0481

Updated

Suction Pumps - CPB 05030503

Updated

Suction Pumps - CPB 0503

0503

Updated

Zenocutuzumab-zbco (Bizengri) - CPB 10761076

Updated

Zenocutuzumab-zbco (Bizengri) - CPB 1076

1076

Jul 2, 2026

Aetna

Updated

Coblation - CPB 04750475

Updated

Coblation - CPB 0475

0475

Updated

Edaravone Injection - CPB 09180918

Updated

Edaravone Injection - CPB 0918

0918

Updated

Hematopoietic Cell Transplantation for Hodgkin's Disease - CPB 04950495

Updated

Hematopoietic Cell Transplantation for Hodgkin's Disease - CPB 0495

0495

Updated

Meniere's Disease Surgery - CPB 05140514

Updated

Meniere's Disease Surgery - CPB 0514

0514

Updated

Necitumumab (Portrazza) - CPB 08980898

Updated

Necitumumab (Portrazza) - CPB 0898

0898

Updated

Nitric Oxide, Inhalational (INO) - CPB 05180518

Updated

Nitric Oxide, Inhalational (INO) - CPB 0518

0518

Updated

Standing Frames, Tables, and Transfer Boards - CPB 04810481

Updated

Standing Frames, Tables, and Transfer Boards - CPB 0481

0481

Updated

Suction Pumps - CPB 05030503

Updated

Suction Pumps - CPB 0503

0503

Updated

Zenocutuzumab-zbco (Bizengri) - CPB 10761076

Updated

Zenocutuzumab-zbco (Bizengri) - CPB 1076

1076

Jul 1, 2026

Aetna

Updated

Abatacept (Orencia) - CPB 07200720

Updated

Abatacept (Orencia) - CPB 0720

0720

Updated

Certolizumab Pegol (Cimzia) - CPB 07610761

Updated

Certolizumab Pegol (Cimzia) - CPB 0761

0761

Updated

Clinical Trials, Coverage of Routine Patient Care Costs - CPB 04660466

Updated

Clinical Trials, Coverage of Routine Patient Care Costs - CPB 0466

0466

Updated

Early Intervention Programs - CPB 04440444

Updated

Early Intervention Programs - CPB 0444

0444

Updated

Enuresis - CPB 04310431

Updated

Enuresis - CPB 0431

0431

Updated

Gender Affirming Surgery - CPB 06150615

Updated

Gender Affirming Surgery - CPB 0615

0615

Updated

Herpes Simplex Virus - Screening and Diagnosis - CPB 04330433

Updated

Herpes Simplex Virus - Screening and Diagnosis - CPB 0433

0433

Updated

Intravenous Iron Therapy - CPB 05750575

Updated

Intravenous Iron Therapy - CPB 0575

0575

Updated

Mirikizumab-mrkz (Omvoh) - CPB 10481048

Updated

Mirikizumab-mrkz (Omvoh) - CPB 1048

1048

Updated

Positive Pressure Ventilation - CPB 04520452

Updated

Positive Pressure Ventilation - CPB 0452

0452

Updated

Risankizumab-rzaa (Skyrizi) - CPB 10091009

Updated

Risankizumab-rzaa (Skyrizi) - CPB 1009

1009

Updated

Speech Generating Devices - CPB 04370437

Updated

Speech Generating Devices - CPB 0437

0437

Updated

Tildrakizumab-asmn (Ilumya) - CPB 10121012

Updated

Tildrakizumab-asmn (Ilumya) - CPB 1012

1012

Updated

Ustekinumab - CPB 09120912

Updated

Ustekinumab - CPB 0912

0912

Anthem Blue Cross Blue Shield Missouri

New

CG-MED-107 Autonomic TestingCG-MED-107

New

CG-MED-107 Autonomic Testing

CG-MED-107

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy) CG-RAD-33

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy)

CG-RAD-33

New

CG-SURG-134 Treatments for Urinary IncontinenceCG-SURG-134

New

CG-SURG-134 Treatments for Urinary Incontinence

CG-SURG-134

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat RhinitisCG-SURG-135

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

CG-SURG-135

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer TreatmentDME.00056

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer Treatment

DME.00056

New

MED.00166 Mucosal Integrity TestingMED.00166

New

MED.00166 Mucosal Integrity Testing

MED.00166

Updated

ADMIN.00002 Preventive Health GuidelinesADMIN.00002

Updated

ADMIN.00002 Preventive Health Guidelines

ADMIN.00002

Updated

ADMIN.00004 Medical Necessity CriteriaADMIN.00004

Updated

ADMIN.00004 Medical Necessity Criteria

ADMIN.00004

Updated

ADMIN.00005 Investigational CriteriaADMIN.00005

Updated

ADMIN.00005 Investigational Criteria

ADMIN.00005

Updated

ANC.00006 Biomagnetic TherapyANC.00006

Updated

ANC.00006 Biomagnetic Therapy

ANC.00006

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and ExtremitiesANC.00009

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities

ANC.00009

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline ExistsCG-ADMIN-01

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

CG-ADMIN-01

Updated

CG-ANC-06 Ambulance Services: Ground; Non-EmergentCG-ANC-06

Updated

CG-ANC-06 Ambulance Services: Ground; Non-Emergent

CG-ANC-06

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle AtrophyCG-DME-03

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy

CG-DME-03

Updated

CG-DME-05 Cervical Traction Devices for Home UseCG-DME-05

Updated

CG-DME-05 Cervical Traction Devices for Home Use

CG-DME-05

Updated

CG-DME-08 Infant Home Apnea MonitorsCG-DME-08

Updated

CG-DME-08 Infant Home Apnea Monitors

CG-DME-08

Updated

CG-DME-20 Orthopedic FootwearCG-DME-20

Updated

CG-DME-20 Orthopedic Footwear

CG-DME-20

Updated

CG-DME-35 Electric Breast PumpsCG-DME-35

Updated

CG-DME-35 Electric Breast Pumps

CG-DME-35

Updated

CG-DME-36 Pediatric Gait TrainersCG-DME-36

Updated

CG-DME-36 Pediatric Gait Trainers

CG-DME-36

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch DevicesCG-DME-39

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices

CG-DME-39

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) Therapy

CG-DME-44

Updated

CG-DME-45 Ultrasound Bone Growth StimulationCG-DME-45

Updated

CG-DME-45 Ultrasound Bone Growth Stimulation

CG-DME-45

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home SettingCG-DME-46

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

CG-DME-46

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory FailureCG-DME-47

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure

CG-DME-47

Updated

CG-DME-49 Standing FramesCG-DME-49

Updated

CG-DME-49 Standing Frames

CG-DME-49

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation DevicesCG-DME-54

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation Devices

CG-DME-54

Updated

CG-LAB-12 Testing for Oral and Esophageal CancerCG-LAB-12

Updated

CG-LAB-12 Testing for Oral and Esophageal Cancer

CG-LAB-12

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of VaginitisCG-LAB-22

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Vaginitis

CG-LAB-22

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein TestingCG-LAB-25

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing

CG-LAB-25

Updated

CG-LAB-29 Gamma Glutamyl Transferase TestingCG-LAB-29

Updated

CG-LAB-29 Gamma Glutamyl Transferase Testing

CG-LAB-29

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose TestingCG-LAB-30

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing

CG-LAB-30

Updated

CG-LAB-38 Standard Lipid Panel TestingCG-LAB-38

Updated

CG-LAB-38 Standard Lipid Panel Testing

CG-LAB-38

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility SettingCG-MED-41

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

CG-MED-41

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

CG-MED-49

Updated

CG-MED-57 Cardiac Stress Testing with ElectrocardiogramCG-MED-57

Updated

CG-MED-57 Cardiac Stress Testing with Electrocardiogram

CG-MED-57

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in AdultsCG-MED-59

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

CG-MED-59

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian TissueCG-MED-66

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue

CG-MED-66

Updated

CG-MED-69 Inhaled Nitric OxideCG-MED-69

Updated

CG-MED-69 Inhaled Nitric Oxide

CG-MED-69

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency CapsuleCG-MED-70

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

CG-MED-70

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)CG-MED-73

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

CG-MED-73

Updated

CG-MED-89 Home Parenteral NutritionCG-MED-89

Updated

CG-MED-89 Home Parenteral Nutrition

CG-MED-89

Updated

CG-MED-90 Chelation TherapyCG-MED-90

Updated

CG-MED-90 Chelation Therapy

CG-MED-90

Updated

CG-MED-97 Biofeedback and NeurofeedbackCG-MED-97

Updated

CG-MED-97 Biofeedback and Neurofeedback

CG-MED-97

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic DevicesCG-OR-PR-05

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

CG-OR-PR-05

Updated

CG-REHAB-02 Outpatient Cardiac RehabilitationCG-REHAB-02

Updated

CG-REHAB-02 Outpatient Cardiac Rehabilitation

CG-REHAB-02

Updated

CG-REHAB-03 Pulmonary RehabilitationCG-REHAB-03

Updated

CG-REHAB-03 Pulmonary Rehabilitation

CG-REHAB-03

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium RibCG-SURG-07

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib

CG-SURG-07

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett EsophagusCG-SURG-101

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett Esophagus

CG-SURG-101

Updated

CG-SURG-105 Corneal Collagen Cross-LinkingCG-SURG-105

Updated

CG-SURG-105 Corneal Collagen Cross-Linking

CG-SURG-105

Updated

CG-SURG-12 Penile Prosthesis ImplantationCG-SURG-12

Updated

CG-SURG-12 Penile Prosthesis Implantation

CG-SURG-12

Updated

CG-SURG-129 Internal Rib Fixation SystemsCG-SURG-129

Updated

CG-SURG-129 Internal Rib Fixation Systems

CG-SURG-129

Updated

CG-SURG-133 Intraluminal Left Atrial Appendage Closure Devices CG-SURG-133

Updated

CG-SURG-133 Intraluminal Left Atrial Appendage Closure Devices

CG-SURG-133

Updated

CG-SURG-17 Trigger Point InjectionsCG-SURG-17

Updated

CG-SURG-17 Trigger Point Injections

CG-SURG-17

Updated

CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)CG-SURG-24

Updated

CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)

CG-SURG-24

Updated

CG-SURG-25 Injection Treatment for Morton NeuromaCG-SURG-25

Updated

CG-SURG-25 Injection Treatment for Morton Neuroma

CG-SURG-25

Updated

CG-SURG-31 Treatment of Keloids and Scar RevisionCG-SURG-31

Updated

CG-SURG-31 Treatment of Keloids and Scar Revision

CG-SURG-31

Updated

CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)CG-SURG-35

Updated

CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)

CG-SURG-35

Updated

CG-SURG-50 Assistant SurgeonsCG-SURG-50

Updated

CG-SURG-50 Assistant Surgeons

CG-SURG-50

Updated

CG-SURG-51 Outpatient CystourethroscopyCG-SURG-51

Updated

CG-SURG-51 Outpatient Cystourethroscopy

CG-SURG-51

Updated

CG-SURG-56 Diagnostic Fiberoptic Flexible LaryngoscopyCG-SURG-56

Updated

CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy

CG-SURG-56

Updated

CG-SURG-71 Reduction MammaplastyCG-SURG-71

Updated

CG-SURG-71 Reduction Mammaplasty

CG-SURG-71

Updated

CG-SURG-73 Balloon Sinus Ostial DilationCG-SURG-73

Updated

CG-SURG-73 Balloon Sinus Ostial Dilation

CG-SURG-73

Updated

CG-SURG-81 Cochlear Implants and Auditory Brainstem ImplantsCG-SURG-81

Updated

CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants

CG-SURG-81

Updated

CG-SURG-82 Bone-Anchored and Bone Conduction Hearing AidsCG-SURG-82

Updated

CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids

CG-SURG-82

Updated

CG-SURG-84 Mandibular/Maxillary (Orthognathic) SurgeryCG-SURG-84

Updated

CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery

CG-SURG-84

Updated

CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal NeuralgiaCG-SURG-89

Updated

CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

CG-SURG-89

Updated

CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell TransplantationCG-TRANS-03

Updated

CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

CG-TRANS-03

Updated

DME.00012 Intrapulmonary Percussive Ventilation DevicesDME.00012

Updated

DME.00012 Intrapulmonary Percussive Ventilation Devices

DME.00012

Updated

DME.00030 Altered Auditory Feedback Devices for Fluency DisordersDME.00030

Updated

DME.00030 Altered Auditory Feedback Devices for Fluency Disorders

DME.00030

Updated

DME.00037 Cooling Devices and Combined Cooling/Heating DevicesDME.00037

Updated

DME.00037 Cooling Devices and Combined Cooling/Heating Devices

DME.00037

Updated

DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) DevicesDME.00038

Updated

DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

DME.00038

Updated

DME.00046 Intermittent Abdominal Pressure Ventilation DevicesDME.00046

Updated

DME.00046 Intermittent Abdominal Pressure Ventilation Devices

DME.00046

Updated

DME.00047 Rehabilitative Devices with Remote MonitoringDME.00047

Updated

DME.00047 Rehabilitative Devices with Remote Monitoring

DME.00047

Updated

DME.00048 Virtual Reality-Assisted Therapy SystemsDME.00048

Updated

DME.00048 Virtual Reality-Assisted Therapy Systems

DME.00048

Updated

DME.00049 External Upper Limb Stimulation for the Treatment of TremorsDME.00049

Updated

DME.00049 External Upper Limb Stimulation for the Treatment of Tremors

DME.00049

Updated

DME.00054 Gait Modulation Systems Using Rhythmic Auditory StimulationDME.00054

Updated

DME.00054 Gait Modulation Systems Using Rhythmic Auditory Stimulation

DME.00054

Updated

LAB.00011 Selected Protein Biomarker Algorithmic AssaysLAB.00011

Updated

LAB.00011 Selected Protein Biomarker Algorithmic Assays

LAB.00011

Updated

LAB.00016 Fecal Analysis Panels in the Diagnosis of Intestinal DisordersLAB.00016

Updated

LAB.00016 Fecal Analysis Panels in the Diagnosis of Intestinal Disorders

LAB.00016

Updated

LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity TestsLAB.00027

Updated

LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests

LAB.00027

Updated

LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid ArthritisLAB.00035

Updated

LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis

LAB.00035

Updated

LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)LAB.00037

Updated

LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

LAB.00037

Updated

LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function DeclineLAB.00041

Updated

LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline

LAB.00041

Updated

LAB.00046 Testing for Biochemical Markers for Alzheimer DiseaseLAB.00046

Updated

LAB.00046 Testing for Biochemical Markers for Alzheimer Disease

LAB.00046

Updated

LAB.00048 Analysis of Urine Biomarkers for Chronic Pain ManagementLAB.00048

Updated

LAB.00048 Analysis of Urine Biomarkers for Chronic Pain Management

LAB.00048

Updated

MED.00090 Wireless Capsules for the Evaluation of Suspected Gastric and Intestinal Motility DisordersMED.00090

Updated

MED.00090 Wireless Capsules for the Evaluation of Suspected Gastric and Intestinal Motility Disorders

MED.00090

Updated

MED.00098 Hyperoxemic Reperfusion TherapyMED.00098

Updated

MED.00098 Hyperoxemic Reperfusion Therapy

MED.00098

Updated

MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129

Updated

MED.00129 Gene Therapy for Spinal Muscular Atrophy

MED.00129

Updated

MED.00133 Ingestion Event MonitorsMED.00133

Updated

MED.00133 Ingestion Event Monitors

MED.00133

Updated

MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of ConcussionMED.00137

Updated

MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion

MED.00137

Updated

MED.00139 Electrical Impedance Scanning for Cancer DetectionMED.00139

Updated

MED.00139 Electrical Impedance Scanning for Cancer Detection

MED.00139

Updated

MED.00140 Gene Therapy for Beta Thalassemia MED.00140

Updated

MED.00140 Gene Therapy for Beta Thalassemia

MED.00140

Updated

MED.00142 Gene Therapy for Cerebral AdrenoleukodystrophyMED.00142

Updated

MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy

MED.00142

Updated

MED.00148 Gene Therapy for Metachromatic LeukodystrophyMED.00148

Updated

MED.00148 Gene Therapy for Metachromatic Leukodystrophy

MED.00148

Updated

MED.00155 Allogeneic Bone Marrow-Derived Mesenchymal Stromal Cell TherapyMED.00155

Updated

MED.00155 Allogeneic Bone Marrow-Derived Mesenchymal Stromal Cell Therapy

MED.00155

Updated

OR-PR.00005 Upper Extremity Myoelectric OrthosesOR-PR.00005

Updated

OR-PR.00005 Upper Extremity Myoelectric Orthoses

OR-PR.00005

Updated

OR-PR.00006 Powered Robotic Lower Body Exoskeleton DevicesOR-PR.00006

Updated

OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices

OR-PR.00006

Updated

SURG.00019 Transmyocardial RevascularizationSURG.00019

Updated

SURG.00019 Transmyocardial Revascularization

SURG.00019

Updated

SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast ProceduresSURG.00023

Updated

SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

SURG.00023

Updated

SURG.00045 Extracorporeal Shock Wave Therapy SURG.00045

Updated

SURG.00045 Extracorporeal Shock Wave Therapy

SURG.00045

Updated

SURG.00052 Percutaneous Vertebral Disc ProceduresSURG.00052

Updated

SURG.00052 Percutaneous Vertebral Disc Procedures

SURG.00052

Updated

SURG.00071 Percutaneous Spinal SurgerySURG.00071

Updated

SURG.00071 Percutaneous Spinal Surgery

SURG.00071

Updated

SURG.00084 Implantable Middle Ear Hearing AidsSURG.00084

Updated

SURG.00084 Implantable Middle Ear Hearing Aids

SURG.00084

Updated

SURG.00111 Axial Lumbar Interbody FusionSURG.00111

Updated

SURG.00111 Axial Lumbar Interbody Fusion

SURG.00111

Updated

SURG.00118 Bronchial ThermoplastySURG.00118

Updated

SURG.00118 Bronchial Thermoplasty

SURG.00118

Updated

SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point PainSURG.00125

Updated

SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain

SURG.00125

Updated

SURG.00126 Irreversible Electroporation SURG.00126

Updated

SURG.00126 Irreversible Electroporation

SURG.00126

Updated

SURG.00134 Interspinous Process Fixation DevicesSURG.00134

Updated

SURG.00134 Interspinous Process Fixation Devices

SURG.00134

Updated

SURG.00141 Doppler-Guided Transanal Hemorrhoidal DearterializationSURG.00141

Updated

SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization

SURG.00141

Updated

SURG.00155 Cryosurgery of Peripheral NervesSURG.00155

Updated

SURG.00155 Cryosurgery of Peripheral Nerves

SURG.00155

Updated

SURG.00161 Nanoparticle-Mediated Thermal AblationSURG.00161

Updated

SURG.00161 Nanoparticle-Mediated Thermal Ablation

SURG.00161

Updated

SURG.00165 HistotripsySURG.00165

Updated

SURG.00165 Histotripsy

SURG.00165

Updated

THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac RadioablationTHER-RAD.00012

Updated

THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation

THER-RAD.00012

Updated

TRANS.00008 Liver TransplantationTRANS.00008

Updated

TRANS.00008 Liver Transplantation

TRANS.00008

Updated

TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin LymphomaTRANS.00028

Updated

TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma

TRANS.00028

Updated

TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid TumorsTRANS.00031

Updated

TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

TRANS.00031

Updated

TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035

Updated

TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products

TRANS.00035

Anthem Blue Cross Blue Shield Ohio

New

CG-MED-107 Autonomic TestingCG-MED-107

New

CG-MED-107 Autonomic Testing

CG-MED-107

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy) CG-RAD-33

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy)

CG-RAD-33

New

CG-SURG-134 Treatments for Urinary IncontinenceCG-SURG-134

New

CG-SURG-134 Treatments for Urinary Incontinence

CG-SURG-134

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat RhinitisCG-SURG-135

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

CG-SURG-135

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer TreatmentDME.00056

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer Treatment

DME.00056

New

MED.00166 Mucosal Integrity TestingMED.00166

New

MED.00166 Mucosal Integrity Testing

MED.00166

Updated

ADMIN.00002 Preventive Health GuidelinesADMIN.00002

Updated

ADMIN.00002 Preventive Health Guidelines

ADMIN.00002

Updated

ADMIN.00004 Medical Necessity CriteriaADMIN.00004

Updated

ADMIN.00004 Medical Necessity Criteria

ADMIN.00004

Updated

ADMIN.00005 Investigational CriteriaADMIN.00005

Updated

ADMIN.00005 Investigational Criteria

ADMIN.00005

Updated

ANC.00006 Biomagnetic TherapyANC.00006

Updated

ANC.00006 Biomagnetic Therapy

ANC.00006

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and ExtremitiesANC.00009

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities

ANC.00009

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline ExistsCG-ADMIN-01

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

CG-ADMIN-01

Updated

CG-ANC-06 Ambulance Services: Ground; Non-EmergentCG-ANC-06

Updated

CG-ANC-06 Ambulance Services: Ground; Non-Emergent

CG-ANC-06

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle AtrophyCG-DME-03

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy

CG-DME-03

Updated

CG-DME-05 Cervical Traction Devices for Home UseCG-DME-05

Updated

CG-DME-05 Cervical Traction Devices for Home Use

CG-DME-05

Updated

CG-DME-08 Infant Home Apnea MonitorsCG-DME-08

Updated

CG-DME-08 Infant Home Apnea Monitors

CG-DME-08

Updated

CG-DME-20 Orthopedic FootwearCG-DME-20

Updated

CG-DME-20 Orthopedic Footwear

CG-DME-20

Updated

CG-DME-35 Electric Breast PumpsCG-DME-35

Updated

CG-DME-35 Electric Breast Pumps

CG-DME-35

Updated

CG-DME-36 Pediatric Gait TrainersCG-DME-36

Updated

CG-DME-36 Pediatric Gait Trainers

CG-DME-36

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch DevicesCG-DME-39

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices

CG-DME-39

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) Therapy

CG-DME-44

Updated

CG-DME-45 Ultrasound Bone Growth StimulationCG-DME-45

Updated

CG-DME-45 Ultrasound Bone Growth Stimulation

CG-DME-45

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home SettingCG-DME-46

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

CG-DME-46

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory FailureCG-DME-47

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure

CG-DME-47

Updated

CG-DME-49 Standing FramesCG-DME-49

Updated

CG-DME-49 Standing Frames

CG-DME-49

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation DevicesCG-DME-54

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation Devices

CG-DME-54

Updated

CG-LAB-12 Testing for Oral and Esophageal CancerCG-LAB-12

Updated

CG-LAB-12 Testing for Oral and Esophageal Cancer

CG-LAB-12

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of VaginitisCG-LAB-22

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Vaginitis

CG-LAB-22

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein TestingCG-LAB-25

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing

CG-LAB-25

Updated

CG-LAB-29 Gamma Glutamyl Transferase TestingCG-LAB-29

Updated

CG-LAB-29 Gamma Glutamyl Transferase Testing

CG-LAB-29

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose TestingCG-LAB-30

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing

CG-LAB-30

Updated

CG-LAB-38 Standard Lipid Panel TestingCG-LAB-38

Updated

CG-LAB-38 Standard Lipid Panel Testing

CG-LAB-38

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility SettingCG-MED-41

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

CG-MED-41

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

CG-MED-49

Updated

CG-MED-57 Cardiac Stress Testing with ElectrocardiogramCG-MED-57

Updated

CG-MED-57 Cardiac Stress Testing with Electrocardiogram

CG-MED-57

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in AdultsCG-MED-59

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

CG-MED-59

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian TissueCG-MED-66

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue

CG-MED-66

Updated

CG-MED-69 Inhaled Nitric OxideCG-MED-69

Updated

CG-MED-69 Inhaled Nitric Oxide

CG-MED-69

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency CapsuleCG-MED-70

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

CG-MED-70

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)CG-MED-73

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

CG-MED-73

Updated

CG-MED-89 Home Parenteral NutritionCG-MED-89

Updated

CG-MED-89 Home Parenteral Nutrition

CG-MED-89

Updated

CG-MED-90 Chelation TherapyCG-MED-90

Updated

CG-MED-90 Chelation Therapy

CG-MED-90

Updated

CG-MED-97 Biofeedback and NeurofeedbackCG-MED-97

Updated

CG-MED-97 Biofeedback and Neurofeedback

CG-MED-97

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic DevicesCG-OR-PR-05

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

CG-OR-PR-05

Updated

CG-REHAB-02 Outpatient Cardiac RehabilitationCG-REHAB-02

Updated

CG-REHAB-02 Outpatient Cardiac Rehabilitation

CG-REHAB-02

Updated

CG-REHAB-03 Pulmonary RehabilitationCG-REHAB-03

Updated

CG-REHAB-03 Pulmonary Rehabilitation

CG-REHAB-03

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium RibCG-SURG-07

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib

CG-SURG-07

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett EsophagusCG-SURG-101

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett Esophagus

CG-SURG-101

Jul 1, 2026

Aetna

Updated

Abatacept (Orencia) - CPB 07200720

Updated

Abatacept (Orencia) - CPB 0720

0720

Updated

Certolizumab Pegol (Cimzia) - CPB 07610761

Updated

Certolizumab Pegol (Cimzia) - CPB 0761

0761

Updated

Clinical Trials, Coverage of Routine Patient Care Costs - CPB 04660466

Updated

Clinical Trials, Coverage of Routine Patient Care Costs - CPB 0466

0466

Updated

Early Intervention Programs - CPB 04440444

Updated

Early Intervention Programs - CPB 0444

0444

Updated

Enuresis - CPB 04310431

Updated

Enuresis - CPB 0431

0431

Updated

Gender Affirming Surgery - CPB 06150615

Updated

Gender Affirming Surgery - CPB 0615

0615

Updated

Herpes Simplex Virus - Screening and Diagnosis - CPB 04330433

Updated

Herpes Simplex Virus - Screening and Diagnosis - CPB 0433

0433

Updated

Intravenous Iron Therapy - CPB 05750575

Updated

Intravenous Iron Therapy - CPB 0575

0575

Updated

Mirikizumab-mrkz (Omvoh) - CPB 10481048

Updated

Mirikizumab-mrkz (Omvoh) - CPB 1048

1048

Updated

Positive Pressure Ventilation - CPB 04520452

Updated

Positive Pressure Ventilation - CPB 0452

0452

Updated

Risankizumab-rzaa (Skyrizi) - CPB 10091009

Updated

Risankizumab-rzaa (Skyrizi) - CPB 1009

1009

Updated

Speech Generating Devices - CPB 04370437

Updated

Speech Generating Devices - CPB 0437

0437

Updated

Tildrakizumab-asmn (Ilumya) - CPB 10121012

Updated

Tildrakizumab-asmn (Ilumya) - CPB 1012

1012

Updated

Ustekinumab - CPB 09120912

Updated

Ustekinumab - CPB 0912

0912

Anthem Blue Cross Blue Shield Missouri

New

CG-MED-107 Autonomic TestingCG-MED-107

New

CG-MED-107 Autonomic Testing

CG-MED-107

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy) CG-RAD-33

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy)

CG-RAD-33

New

CG-SURG-134 Treatments for Urinary IncontinenceCG-SURG-134

New

CG-SURG-134 Treatments for Urinary Incontinence

CG-SURG-134

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat RhinitisCG-SURG-135

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

CG-SURG-135

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer TreatmentDME.00056

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer Treatment

DME.00056

New

MED.00166 Mucosal Integrity TestingMED.00166

New

MED.00166 Mucosal Integrity Testing

MED.00166

Updated

ADMIN.00002 Preventive Health GuidelinesADMIN.00002

Updated

ADMIN.00002 Preventive Health Guidelines

ADMIN.00002

Updated

ADMIN.00004 Medical Necessity CriteriaADMIN.00004

Updated

ADMIN.00004 Medical Necessity Criteria

ADMIN.00004

Updated

ADMIN.00005 Investigational CriteriaADMIN.00005

Updated

ADMIN.00005 Investigational Criteria

ADMIN.00005

Updated

ANC.00006 Biomagnetic TherapyANC.00006

Updated

ANC.00006 Biomagnetic Therapy

ANC.00006

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and ExtremitiesANC.00009

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities

ANC.00009

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline ExistsCG-ADMIN-01

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

CG-ADMIN-01

Updated

CG-ANC-06 Ambulance Services: Ground; Non-EmergentCG-ANC-06

Updated

CG-ANC-06 Ambulance Services: Ground; Non-Emergent

CG-ANC-06

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle AtrophyCG-DME-03

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy

CG-DME-03

Updated

CG-DME-05 Cervical Traction Devices for Home UseCG-DME-05

Updated

CG-DME-05 Cervical Traction Devices for Home Use

CG-DME-05

Updated

CG-DME-08 Infant Home Apnea MonitorsCG-DME-08

Updated

CG-DME-08 Infant Home Apnea Monitors

CG-DME-08

Updated

CG-DME-20 Orthopedic FootwearCG-DME-20

Updated

CG-DME-20 Orthopedic Footwear

CG-DME-20

Updated

CG-DME-35 Electric Breast PumpsCG-DME-35

Updated

CG-DME-35 Electric Breast Pumps

CG-DME-35

Updated

CG-DME-36 Pediatric Gait TrainersCG-DME-36

Updated

CG-DME-36 Pediatric Gait Trainers

CG-DME-36

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch DevicesCG-DME-39

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices

CG-DME-39

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) Therapy

CG-DME-44

Updated

CG-DME-45 Ultrasound Bone Growth StimulationCG-DME-45

Updated

CG-DME-45 Ultrasound Bone Growth Stimulation

CG-DME-45

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home SettingCG-DME-46

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

CG-DME-46

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory FailureCG-DME-47

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure

CG-DME-47

Updated

CG-DME-49 Standing FramesCG-DME-49

Updated

CG-DME-49 Standing Frames

CG-DME-49

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation DevicesCG-DME-54

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation Devices

CG-DME-54

Updated

CG-LAB-12 Testing for Oral and Esophageal CancerCG-LAB-12

Updated

CG-LAB-12 Testing for Oral and Esophageal Cancer

CG-LAB-12

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of VaginitisCG-LAB-22

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Vaginitis

CG-LAB-22

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein TestingCG-LAB-25

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing

CG-LAB-25

Updated

CG-LAB-29 Gamma Glutamyl Transferase TestingCG-LAB-29

Updated

CG-LAB-29 Gamma Glutamyl Transferase Testing

CG-LAB-29

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose TestingCG-LAB-30

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing

CG-LAB-30

Updated

CG-LAB-38 Standard Lipid Panel TestingCG-LAB-38

Updated

CG-LAB-38 Standard Lipid Panel Testing

CG-LAB-38

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility SettingCG-MED-41

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

CG-MED-41

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

CG-MED-49

Updated

CG-MED-57 Cardiac Stress Testing with ElectrocardiogramCG-MED-57

Updated

CG-MED-57 Cardiac Stress Testing with Electrocardiogram

CG-MED-57

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in AdultsCG-MED-59

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

CG-MED-59

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian TissueCG-MED-66

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue

CG-MED-66

Updated

CG-MED-69 Inhaled Nitric OxideCG-MED-69

Updated

CG-MED-69 Inhaled Nitric Oxide

CG-MED-69

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency CapsuleCG-MED-70

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

CG-MED-70

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)CG-MED-73

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

CG-MED-73

Updated

CG-MED-89 Home Parenteral NutritionCG-MED-89

Updated

CG-MED-89 Home Parenteral Nutrition

CG-MED-89

Updated

CG-MED-90 Chelation TherapyCG-MED-90

Updated

CG-MED-90 Chelation Therapy

CG-MED-90

Updated

CG-MED-97 Biofeedback and NeurofeedbackCG-MED-97

Updated

CG-MED-97 Biofeedback and Neurofeedback

CG-MED-97

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic DevicesCG-OR-PR-05

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

CG-OR-PR-05

Updated

CG-REHAB-02 Outpatient Cardiac RehabilitationCG-REHAB-02

Updated

CG-REHAB-02 Outpatient Cardiac Rehabilitation

CG-REHAB-02

Updated

CG-REHAB-03 Pulmonary RehabilitationCG-REHAB-03

Updated

CG-REHAB-03 Pulmonary Rehabilitation

CG-REHAB-03

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium RibCG-SURG-07

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib

CG-SURG-07

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett EsophagusCG-SURG-101

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett Esophagus

CG-SURG-101

Updated

CG-SURG-105 Corneal Collagen Cross-LinkingCG-SURG-105

Updated

CG-SURG-105 Corneal Collagen Cross-Linking

CG-SURG-105

Updated

CG-SURG-12 Penile Prosthesis ImplantationCG-SURG-12

Updated

CG-SURG-12 Penile Prosthesis Implantation

CG-SURG-12

Updated

CG-SURG-129 Internal Rib Fixation SystemsCG-SURG-129

Updated

CG-SURG-129 Internal Rib Fixation Systems

CG-SURG-129

Updated

CG-SURG-133 Intraluminal Left Atrial Appendage Closure Devices CG-SURG-133

Updated

CG-SURG-133 Intraluminal Left Atrial Appendage Closure Devices

CG-SURG-133

Updated

CG-SURG-17 Trigger Point InjectionsCG-SURG-17

Updated

CG-SURG-17 Trigger Point Injections

CG-SURG-17

Updated

CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)CG-SURG-24

Updated

CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)

CG-SURG-24

Updated

CG-SURG-25 Injection Treatment for Morton NeuromaCG-SURG-25

Updated

CG-SURG-25 Injection Treatment for Morton Neuroma

CG-SURG-25

Updated

CG-SURG-31 Treatment of Keloids and Scar RevisionCG-SURG-31

Updated

CG-SURG-31 Treatment of Keloids and Scar Revision

CG-SURG-31

Updated

CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)CG-SURG-35

Updated

CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)

CG-SURG-35

Updated

CG-SURG-50 Assistant SurgeonsCG-SURG-50

Updated

CG-SURG-50 Assistant Surgeons

CG-SURG-50

Updated

CG-SURG-51 Outpatient CystourethroscopyCG-SURG-51

Updated

CG-SURG-51 Outpatient Cystourethroscopy

CG-SURG-51

Updated

CG-SURG-56 Diagnostic Fiberoptic Flexible LaryngoscopyCG-SURG-56

Updated

CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy

CG-SURG-56

Updated

CG-SURG-71 Reduction MammaplastyCG-SURG-71

Updated

CG-SURG-71 Reduction Mammaplasty

CG-SURG-71

Updated

CG-SURG-73 Balloon Sinus Ostial DilationCG-SURG-73

Updated

CG-SURG-73 Balloon Sinus Ostial Dilation

CG-SURG-73

Updated

CG-SURG-81 Cochlear Implants and Auditory Brainstem ImplantsCG-SURG-81

Updated

CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants

CG-SURG-81

Updated

CG-SURG-82 Bone-Anchored and Bone Conduction Hearing AidsCG-SURG-82

Updated

CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids

CG-SURG-82

Updated

CG-SURG-84 Mandibular/Maxillary (Orthognathic) SurgeryCG-SURG-84

Updated

CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery

CG-SURG-84

Updated

CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal NeuralgiaCG-SURG-89

Updated

CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

CG-SURG-89

Updated

CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell TransplantationCG-TRANS-03

Updated

CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

CG-TRANS-03

Updated

DME.00012 Intrapulmonary Percussive Ventilation DevicesDME.00012

Updated

DME.00012 Intrapulmonary Percussive Ventilation Devices

DME.00012

Updated

DME.00030 Altered Auditory Feedback Devices for Fluency DisordersDME.00030

Updated

DME.00030 Altered Auditory Feedback Devices for Fluency Disorders

DME.00030

Updated

DME.00037 Cooling Devices and Combined Cooling/Heating DevicesDME.00037

Updated

DME.00037 Cooling Devices and Combined Cooling/Heating Devices

DME.00037

Updated

DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) DevicesDME.00038

Updated

DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

DME.00038

Updated

DME.00046 Intermittent Abdominal Pressure Ventilation DevicesDME.00046

Updated

DME.00046 Intermittent Abdominal Pressure Ventilation Devices

DME.00046

Updated

DME.00047 Rehabilitative Devices with Remote MonitoringDME.00047

Updated

DME.00047 Rehabilitative Devices with Remote Monitoring

DME.00047

Updated

DME.00048 Virtual Reality-Assisted Therapy SystemsDME.00048

Updated

DME.00048 Virtual Reality-Assisted Therapy Systems

DME.00048

Updated

DME.00049 External Upper Limb Stimulation for the Treatment of TremorsDME.00049

Updated

DME.00049 External Upper Limb Stimulation for the Treatment of Tremors

DME.00049

Updated

DME.00054 Gait Modulation Systems Using Rhythmic Auditory StimulationDME.00054

Updated

DME.00054 Gait Modulation Systems Using Rhythmic Auditory Stimulation

DME.00054

Updated

LAB.00011 Selected Protein Biomarker Algorithmic AssaysLAB.00011

Updated

LAB.00011 Selected Protein Biomarker Algorithmic Assays

LAB.00011

Updated

LAB.00016 Fecal Analysis Panels in the Diagnosis of Intestinal DisordersLAB.00016

Updated

LAB.00016 Fecal Analysis Panels in the Diagnosis of Intestinal Disorders

LAB.00016

Updated

LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity TestsLAB.00027

Updated

LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests

LAB.00027

Updated

LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid ArthritisLAB.00035

Updated

LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis

LAB.00035

Updated

LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)LAB.00037

Updated

LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

LAB.00037

Updated

LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function DeclineLAB.00041

Updated

LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline

LAB.00041

Updated

LAB.00046 Testing for Biochemical Markers for Alzheimer DiseaseLAB.00046

Updated

LAB.00046 Testing for Biochemical Markers for Alzheimer Disease

LAB.00046

Updated

LAB.00048 Analysis of Urine Biomarkers for Chronic Pain ManagementLAB.00048

Updated

LAB.00048 Analysis of Urine Biomarkers for Chronic Pain Management

LAB.00048

Updated

MED.00090 Wireless Capsules for the Evaluation of Suspected Gastric and Intestinal Motility DisordersMED.00090

Updated

MED.00090 Wireless Capsules for the Evaluation of Suspected Gastric and Intestinal Motility Disorders

MED.00090

Updated

MED.00098 Hyperoxemic Reperfusion TherapyMED.00098

Updated

MED.00098 Hyperoxemic Reperfusion Therapy

MED.00098

Updated

MED.00129 Gene Therapy for Spinal Muscular AtrophyMED.00129

Updated

MED.00129 Gene Therapy for Spinal Muscular Atrophy

MED.00129

Updated

MED.00133 Ingestion Event MonitorsMED.00133

Updated

MED.00133 Ingestion Event Monitors

MED.00133

Updated

MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of ConcussionMED.00137

Updated

MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion

MED.00137

Updated

MED.00139 Electrical Impedance Scanning for Cancer DetectionMED.00139

Updated

MED.00139 Electrical Impedance Scanning for Cancer Detection

MED.00139

Updated

MED.00140 Gene Therapy for Beta Thalassemia MED.00140

Updated

MED.00140 Gene Therapy for Beta Thalassemia

MED.00140

Updated

MED.00142 Gene Therapy for Cerebral AdrenoleukodystrophyMED.00142

Updated

MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy

MED.00142

Updated

MED.00148 Gene Therapy for Metachromatic LeukodystrophyMED.00148

Updated

MED.00148 Gene Therapy for Metachromatic Leukodystrophy

MED.00148

Updated

MED.00155 Allogeneic Bone Marrow-Derived Mesenchymal Stromal Cell TherapyMED.00155

Updated

MED.00155 Allogeneic Bone Marrow-Derived Mesenchymal Stromal Cell Therapy

MED.00155

Updated

OR-PR.00005 Upper Extremity Myoelectric OrthosesOR-PR.00005

Updated

OR-PR.00005 Upper Extremity Myoelectric Orthoses

OR-PR.00005

Updated

OR-PR.00006 Powered Robotic Lower Body Exoskeleton DevicesOR-PR.00006

Updated

OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices

OR-PR.00006

Updated

SURG.00019 Transmyocardial RevascularizationSURG.00019

Updated

SURG.00019 Transmyocardial Revascularization

SURG.00019

Updated

SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast ProceduresSURG.00023

Updated

SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

SURG.00023

Updated

SURG.00045 Extracorporeal Shock Wave Therapy SURG.00045

Updated

SURG.00045 Extracorporeal Shock Wave Therapy

SURG.00045

Updated

SURG.00052 Percutaneous Vertebral Disc ProceduresSURG.00052

Updated

SURG.00052 Percutaneous Vertebral Disc Procedures

SURG.00052

Updated

SURG.00071 Percutaneous Spinal SurgerySURG.00071

Updated

SURG.00071 Percutaneous Spinal Surgery

SURG.00071

Updated

SURG.00084 Implantable Middle Ear Hearing AidsSURG.00084

Updated

SURG.00084 Implantable Middle Ear Hearing Aids

SURG.00084

Updated

SURG.00111 Axial Lumbar Interbody FusionSURG.00111

Updated

SURG.00111 Axial Lumbar Interbody Fusion

SURG.00111

Updated

SURG.00118 Bronchial ThermoplastySURG.00118

Updated

SURG.00118 Bronchial Thermoplasty

SURG.00118

Updated

SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point PainSURG.00125

Updated

SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain

SURG.00125

Updated

SURG.00126 Irreversible Electroporation SURG.00126

Updated

SURG.00126 Irreversible Electroporation

SURG.00126

Updated

SURG.00134 Interspinous Process Fixation DevicesSURG.00134

Updated

SURG.00134 Interspinous Process Fixation Devices

SURG.00134

Updated

SURG.00141 Doppler-Guided Transanal Hemorrhoidal DearterializationSURG.00141

Updated

SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization

SURG.00141

Updated

SURG.00155 Cryosurgery of Peripheral NervesSURG.00155

Updated

SURG.00155 Cryosurgery of Peripheral Nerves

SURG.00155

Updated

SURG.00161 Nanoparticle-Mediated Thermal AblationSURG.00161

Updated

SURG.00161 Nanoparticle-Mediated Thermal Ablation

SURG.00161

Updated

SURG.00165 HistotripsySURG.00165

Updated

SURG.00165 Histotripsy

SURG.00165

Updated

THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac RadioablationTHER-RAD.00012

Updated

THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation

THER-RAD.00012

Updated

TRANS.00008 Liver TransplantationTRANS.00008

Updated

TRANS.00008 Liver Transplantation

TRANS.00008

Updated

TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin LymphomaTRANS.00028

Updated

TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma

TRANS.00028

Updated

TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid TumorsTRANS.00031

Updated

TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

TRANS.00031

Updated

TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow ProductsTRANS.00035

Updated

TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products

TRANS.00035

Anthem Blue Cross Blue Shield Ohio

New

CG-MED-107 Autonomic TestingCG-MED-107

New

CG-MED-107 Autonomic Testing

CG-MED-107

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy) CG-RAD-33

New

CG-RAD-33 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy)

CG-RAD-33

New

CG-SURG-134 Treatments for Urinary IncontinenceCG-SURG-134

New

CG-SURG-134 Treatments for Urinary Incontinence

CG-SURG-134

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat RhinitisCG-SURG-135

New

CG-SURG-135 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

CG-SURG-135

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer TreatmentDME.00056

New

DME.00056 Intrabuccal Amplitude-Modulated Radiofrequency Electromagnetic Field Device for Cancer Treatment

DME.00056

New

MED.00166 Mucosal Integrity TestingMED.00166

New

MED.00166 Mucosal Integrity Testing

MED.00166

Updated

ADMIN.00002 Preventive Health GuidelinesADMIN.00002

Updated

ADMIN.00002 Preventive Health Guidelines

ADMIN.00002

Updated

ADMIN.00004 Medical Necessity CriteriaADMIN.00004

Updated

ADMIN.00004 Medical Necessity Criteria

ADMIN.00004

Updated

ADMIN.00005 Investigational CriteriaADMIN.00005

Updated

ADMIN.00005 Investigational Criteria

ADMIN.00005

Updated

ANC.00006 Biomagnetic TherapyANC.00006

Updated

ANC.00006 Biomagnetic Therapy

ANC.00006

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and ExtremitiesANC.00009

Updated

ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities

ANC.00009

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline ExistsCG-ADMIN-01

Updated

CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

CG-ADMIN-01

Updated

CG-ANC-06 Ambulance Services: Ground; Non-EmergentCG-ANC-06

Updated

CG-ANC-06 Ambulance Services: Ground; Non-Emergent

CG-ANC-06

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle AtrophyCG-DME-03

Updated

CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy

CG-DME-03

Updated

CG-DME-05 Cervical Traction Devices for Home UseCG-DME-05

Updated

CG-DME-05 Cervical Traction Devices for Home Use

CG-DME-05

Updated

CG-DME-08 Infant Home Apnea MonitorsCG-DME-08

Updated

CG-DME-08 Infant Home Apnea Monitors

CG-DME-08

Updated

CG-DME-20 Orthopedic FootwearCG-DME-20

Updated

CG-DME-20 Orthopedic Footwear

CG-DME-20

Updated

CG-DME-35 Electric Breast PumpsCG-DME-35

Updated

CG-DME-35 Electric Breast Pumps

CG-DME-35

Updated

CG-DME-36 Pediatric Gait TrainersCG-DME-36

Updated

CG-DME-36 Pediatric Gait Trainers

CG-DME-36

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch DevicesCG-DME-39

Updated

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices

CG-DME-39

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) TherapyCG-DME-44

Updated

CG-DME-44 Electric Tumor Treatment Field (TTF) Therapy

CG-DME-44

Updated

CG-DME-45 Ultrasound Bone Growth StimulationCG-DME-45

Updated

CG-DME-45 Ultrasound Bone Growth Stimulation

CG-DME-45

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home SettingCG-DME-46

Updated

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

CG-DME-46

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory FailureCG-DME-47

Updated

CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure

CG-DME-47

Updated

CG-DME-49 Standing FramesCG-DME-49

Updated

CG-DME-49 Standing Frames

CG-DME-49

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation DevicesCG-DME-54

Updated

CG-DME-54 Mechanical Insufflation-Exsufflation Devices

CG-DME-54

Updated

CG-LAB-12 Testing for Oral and Esophageal CancerCG-LAB-12

Updated

CG-LAB-12 Testing for Oral and Esophageal Cancer

CG-LAB-12

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of VaginitisCG-LAB-22

Updated

CG-LAB-22 Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Vaginitis

CG-LAB-22

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein TestingCG-LAB-25

Updated

CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing

CG-LAB-25

Updated

CG-LAB-29 Gamma Glutamyl Transferase TestingCG-LAB-29

Updated

CG-LAB-29 Gamma Glutamyl Transferase Testing

CG-LAB-29

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose TestingCG-LAB-30

Updated

CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing

CG-LAB-30

Updated

CG-LAB-38 Standard Lipid Panel TestingCG-LAB-38

Updated

CG-LAB-38 Standard Lipid Panel Testing

CG-LAB-38

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility SettingCG-MED-41

Updated

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

CG-MED-41

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing DisordersCG-MED-49

Updated

CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

CG-MED-49

Updated

CG-MED-57 Cardiac Stress Testing with ElectrocardiogramCG-MED-57

Updated

CG-MED-57 Cardiac Stress Testing with Electrocardiogram

CG-MED-57

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in AdultsCG-MED-59

Updated

CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

CG-MED-59

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian TissueCG-MED-66

Updated

CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue

CG-MED-66

Updated

CG-MED-69 Inhaled Nitric OxideCG-MED-69

Updated

CG-MED-69 Inhaled Nitric Oxide

CG-MED-69

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency CapsuleCG-MED-70

Updated

CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

CG-MED-70

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)CG-MED-73

Updated

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

CG-MED-73

Updated

CG-MED-89 Home Parenteral NutritionCG-MED-89

Updated

CG-MED-89 Home Parenteral Nutrition

CG-MED-89

Updated

CG-MED-90 Chelation TherapyCG-MED-90

Updated

CG-MED-90 Chelation Therapy

CG-MED-90

Updated

CG-MED-97 Biofeedback and NeurofeedbackCG-MED-97

Updated

CG-MED-97 Biofeedback and Neurofeedback

CG-MED-97

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic DevicesCG-OR-PR-05

Updated

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

CG-OR-PR-05

Updated

CG-REHAB-02 Outpatient Cardiac RehabilitationCG-REHAB-02

Updated

CG-REHAB-02 Outpatient Cardiac Rehabilitation

CG-REHAB-02

Updated

CG-REHAB-03 Pulmonary RehabilitationCG-REHAB-03

Updated

CG-REHAB-03 Pulmonary Rehabilitation

CG-REHAB-03

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium RibCG-SURG-07

Updated

CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib

CG-SURG-07

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett EsophagusCG-SURG-101

Updated

CG-SURG-101 Ablative Techniques as a Treatment for Barrett Esophagus

CG-SURG-101

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