ACG-FOS Demonstration Project
Medical Necessity Documentation Toolset
Durable Medical Equipment
Ankle-Foot/Knee-Ankle-Foot Orthosis
Canes
&
Crutches
Cervical
Traction
Devices
Commodes
Continuous Passive Motion (CPM) Machines
Custom Knee Braces
Electrical Bone Growth Stimulation: Noninvasive
Electrical Nerve Stimulation, Transcutaneous, Percutaneous
Foot Orthoses, Foot Care Services
Heating Pads
&
Heat Lamps
Hospital Beds
&
Accessories
Lower Limb Prostheses
Negative Pressure Wound Therapy Pumps
Neuromuscular Stimulation in the Treatment of Muscle Atrophy
Orthopedic Footwear
Patient
Lifts
Pediatric Gait Trainers
Power Operated Vehicle (POV)
Prefabricated & Prophylactic Knee Braces
Pressure Reducing Support Surfaces - Group 1
Pressure Reducing Support Surfaces - Group 2
Pressure Reducing Support Surfaces - Group 3
Scoliosis Braces
& Casts
Seat Lift Mechanisms
Spinal Orthoses: TLSO and LSO
SUPPLIES TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) & NEUROMUSCULAR ELECTRICAL STIMULATION (NMES)
Surgical Dressings
Therapeutic Shoes for Persons with Diabetes
Drugs & Biologicals
Imaging
Select Sub-section
MRI
of the Ankle & Hindfoot
MRI
Elbow
MRI
Hip
MRI
Shoulder
Magnetic Resonance
Imaging (MRI) Lumbar Spine
Commercial
MRI
Upper Extremity
MRI of Joints
SPECT Scan for Evaluation of Spondylolysis, Spondylolisthesis & Skeletal Disorders
Duplex Scan Of Lower Extremity Arteries
Non-Invasive Evaluation of Extremity Veins
Non-Vascular Extremity Ultrasound
Cervical Artificial Intervertebral
Disc
Cervical
Fusion
Cervical Laminectomy Other Than for Herniated Disc
Cervical Laminoplasty
Cervical Laminectomy for Herniated Disc
Cervical
Spine
Surgery
Coccygectomy & Treatments for Coccydynia
Destruction of Paravertebral Facet Joint Nerve(s)
Discography
Dorsal Column Stimulation
Endoscopic & Percutaneous Lysis of Epidural Adhesions
Epidural
Facet Joint Denervation
Facet Joint Injections, Medial Branch Blocks, & Facet Joint Radiofrequency
Growing Rods for Spinal Surgery
Idiopathic Scoliosis Treatment
Interspinous Process Decompression
Lumbar Spinal Fusion
Lumbar Total Disc Arthroplasty (TDA)
Pedicle Screws for Spinal Fixation & Intervertebral Body Fusion Devices
Paravertebral Facet Joint
Block
Spinal Cord Stimulation (Dorsal Column Stimulation)
Spinal Decompression Surgery
Surgical Correction of Pectus Excavatum & Poland's Syndrome
Thoracic Laminectomy (and/or Thoracic Diskectomy & Fusion)
Thoracoscopic Sympathectomy
Total Artificial Disc Replacement for the Spine
Shoulder Arthrodesis
Shoulder Arthroplasty
Shoulder Arthroplasty Revision
Shoulder Arthroscopy
Shoulder Arthroscopy-Slap Repair or Biceps Tenodesis
Shoulder Arthroscopy-Claviculectomy/Decompresion-Partial Acromioplasty
Shoulder Arthroscopy-Rotator Cuff
Repair
Carpal Tunnel Surgery
Collagenase Clostridium Histolyticum (Xiaflex ®) for Dupuytren's Contracture
Dupuytren's Contracture -Surgical Treatment
Metacarpo-Phalangeal (MCP)
& Proximal Interphalangeal (PIP) Joint Implants
Nail
Debridement
Wrist, Total
Arthroplasty
Core Decompression for Avascular Necrosis
Distraction Osteosynthesis & Femoral Shortening
Femoroacetabular Impingement Syndrome
Hip, Arthroscopy
Hip Replacement/Arthroplasty
Hip
Resurfacing
Hip Surgery-Arthroscopic
& Open Procedures
Hip, Total
(THA)
Ilizarov Method
of Distraction Osteosynthesis
Outpatient
Total Knee & Total Hip Arthroplasty
Surgical Treatment of Femoroacetabular Impingement Syndrome
Arthroscopic Menisectomy with Osteoarthritis of the Knee
Arthroscopic Anterior Cruciate Ligament Surgery in Skeletally Immature
Arthroscopy for Treatment of Knee Derangement
Articular Cartilage Restoration/Repair of the Knee
Debridement With or Without Chondroplasty
Knee
Diagnostic
Knee Arthroscopy
Elective Knee Arthroscopy & Open Non-Arthroplasty Knee Repair
Knee; Allograft Transplantation of Knee
Knee, Arthroscopy
Knee, Arthroscopy-ACL
Knee, Arthroscopy-Chondroplasty
Knee, Arthroscopy-Fat Pad/Plica Resection
Knee, Arthroscopy-Meniscectomy
Knee, Arthroscopy-PCL
Knee: Autologous Chondrocyte Implantation (ACI)
Knee Surgery: Arthroscopic & Open Procedures
Knee Replacement/Arthroplasty
Knee, Total
(TKA)
Knee
Unicompartmental
Arthroplasty
Knee
Manipulation Under Anesthesia (MUA)
Lateral Release/Patellar Realignment Knee
Ligament Reconstruction/Repair Knee
Loose Body Removal
Knee
Lysis of Adhesions Arthrofibrosis Knee
Meniscectomy/Meniscal Repair Knee
Outpatient
Total Knee & Total Hip Arthroplasty
Total Joint Arthroplasty - Knee
NGS
( L36039 )
Total Joint Arthroplasty - Knee
Noridian
( L36575 )
Ankle,
Arthroscopy
Ankle,
Revision Total
Replacement
Ankle, Total Replacement
Bunionectomy (hallux valgus surgery)
Bunion
Surgery
Debridement of Mycotic Nails
Destruction by Neurolytic Agent; Interdigital Nerve of the Foot—Morton’s Neuroma
EpiFix Wound Treatment
Hammertoe
Repair
Injection of Morton's neuroma
Metatarsal Phalangeal Joint Replacement
Nail
Debridement
Plantar
Fasciitis Treatment
Surgical Treatment of Plantar Fasciitis
Ablative
Therapy of Bone
Arthrocentesis
Botulinum Toxin Type A
& Type B
Collagenase Clostridium Histolyticum (Xiaflex ®) for Dupuytren's Contracture
Complex Regional Pain Syndrome (RSD)
Continuous Peripheral Nerve Blocks
(CPNB)
Debridement Services
Debridement Services of Bone, Muscle, Fascia, & Subcutaneous Tissue
Debridement Services of Extensive Eczematous or Infected Skin
Electrical Bone Growth Stimulation: Noninvasive
Excision of Malignant Skin Lesions- Trunk, Arms, or Legs
Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
Hyaluronan Acid Therapies for Osteoarthritis of the Knee
Hyaluronate Polymers
Implantable Infusion Pump for the Treatment of Chronic Intractable Pain Opioid
Drugs
Implantable Infusion Pump for the Treatment of Chronic Intractable Spasticity
Incision and Drainage of Abscess of Skin, Subcutaneous and Accessory Structures
Injection of
Trigger Points
Internal Fixation of Rib Fracture
Medical
Maggots
Medicinal Leech Therapy
Nerve Blockade for Treatment of Chronic Pain & Neuropathy
Osteopathic Manipulative Treatment
Peripheral
Nerve
Blocks
Recombinant Human Bone Morphogenetic Protein
Treatment of Leg Length Discrepancy
Acute Inpatient Rehabilitation
Chiropractic Services
Constraint-Induced Therapy
EpiFix Wound Treatment
Mechanical Stretching Devices for Joint Stiffness & Contracture
Medical
Maggots
Medicinal Leech Therapy
Occupational Therapy
Osteopathic Manipulative Treatment
Physical
Therapy
Therapy & Rehabilitation Services
Treatment of Decubitus Ulcers
Strapping
Unna
Boot
Wound
Care
™