Noncovered Services/Items

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Antiprothrombin Antibody Testing

Artificial

Retina

Athletic Pubalgia Surgery

AxiaLIF *

Bronchial Thermoplasty

Cancer

Vaccines

Car-Ride Simulators for Infantile Colic

Cold

Therapy

Contact Dissolution for Gallstones

Cosmetic Surgery

Critical Flicker Fusion

Crit-Line

In-Line Monitor

Cytological Examination & Fiberoptic Ductoscopy for Breast Cancer Screening

Dendritic Cell Immunotherapy

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Electrothermal Intradiscal Therapies

Endoscopic Treatment of GERD

Electrical Stimulation for Xerostomia

Electrical Stimulation: Dysphagia

Electrothermal Arthroscopy

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Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)

GlycoMark Testing for Glycemic Control

Hand Transplantation

HLA-DQB1*06:02 Testing for Narcolepsy

Infrared Heating

Pad Systems

Interstitial Laser Therapy

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Knee Ligament Arthrometer Testing

4Kscore

Assay

Laser Neurolysis

Laser Photocoagulation of Drusen

Low Level Laser Therapy (Cold Laser Therapy), High Power Laser Therapy

Macular/Foveal Translocation

Microvascular Therapy in the Treatment of Peripheral Neuropathies

Molecular Diagnostic Tests (MDT)

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Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure

Surgical Decompression for Peripheral Polyneuropathy

Prometheus IBD sgi Diagnostic Policy

Pulsed Radiofrequency

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Radiofrequency Treatment for Urinary Incontinence

Radiofrequency Lesioning for Plantar Fasciitis

RenalVysion

Stereo-lithography

Tinnitus

Masking *

Thermal Intradiscal Procedures

TruFUSE Facet Fusion for Minor Spinal

Ultrasound Therapy for Wound Healing

Unicondylar Interpositional Spacer

Uterine Nerve Ablation (UNA) & Presacral Neurectomy (PSN)

Vagal Nerve Stimulation(VNS) for Intractable  Depression

Vein Embolization:

Ovarian Vein/ Internal Iliac

Vertebral Decompression Therapy

Viscosupple-mentation of Shoulder

Whole Genome/Exome Sequencing & Genome- Wide Association Studies

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