Therapeutics-07

ΨΥΧΗΣ ΙΑΤΡΕΙΟΝ

Select System

Therapeutics

Indicates Non-Covered Service

Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)

Chelation Therapy - Deferoxamine Mesylate (Desferal)

-FloridaBlue-

Chelation Therapy - Dimercaprol (BAL)

Peripheral Artery Disease of the Lower Extremities Angiography, Screening & Exercise Rehabilitation

-Humana-

Allogeneic Hematopoietic Cell Transplantation

Allogeneic Pancreas Transplant

-FloridaBlue-

Autologous & Allogeneic Pancreatic Islet Cell Transplantation

Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

Hematopoietic Stem Cell Transplantation for Genetic Diseases & Aplastic Anemias

Hematopoietic Stem Cell Transplantation for Germ Cell Tumors

Hematopoietic Stem Cell Transplantation for Hodgkin Disease & non-Hodgkin Lymphoma

Hematopoietic Stem Cell Transplantation for Multiple Myeloma & Other Plasma

Cell Dyscrasias

Stem Cell Transplantation: Solid

-Cigna-

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

Hematopoietic Stem Cell Transplantation for Select Leukemias & Myelodysplastic Syndrome

Hematopoietic Stem Cell Transplantation for Thalassemia Major & Sickle Cell Disease

-Aetna-

Stem Cell Transplantation: Blood Cancers

-Cigna-

Umbilical Cord Blood Progenitor Cell Collection, Storage

& Transplantation

Thymus Tissue Transplantation

-Anthem-

Autologous Cellular Therapy for Certain Indications

-UHC-

Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation

-Aetna-

Assessing Your Weight

Healthy Weight & Finding a Balance

Losing Weight

Preventing Weight Gain

Chronic Kidney Disease

Chronic Kidney Disease Basic Education

Chronic Kidney Disease Prevention & Risk Management

Diabetes Care Schedule

Diabetes Education & Support

Diabetes

& Mental Health

Preventing Diabetic Complications & Managing Sick Days

Diabetic Pharmacological Management During Ramadan

Education & Diabetic Management During

Ramadan

Risk Stratification of Patients with T2 DM Who Wish to Fast During Ramadan

Structured Pre-Ramadan Education to Raise Awareness Risks of Diabetes & Fasting

Extended release opioids

Healthy Weight & Eating Well with Diabetes

Healthy Eating for a Healthy Weight

Healthy Weight

Healthy Weight & Finding a Balance

Hospitalization for the Initiation of a Ketogenic Diet

-Aetna-

-Cigna-

Physical Activity for a Healthy Weight

Tips for Parents-Ideas to Help Children Maintain a Healthy Weight

Living with Diabetes

Physical Activity for People with Diabetes

Chronic Pain Programs

-Aetna-

Preparing for Natural Disasters for People with Diabetes

Management of Your Blood Sugar

Managing Your Blood Sugar

Preventing Heart Disease

Preventing Heart Disease & Choosing Healthy Habits

Preventing Heart Disease & Knowing Your Risk for Heart Disease

Adult Preventive Health Guidelines

Quick Screen to Identify Excessive Drinking

Chronic

Vertigo Treatment

Dysphagia/Swallowing Diagnosis & Therapy

-Humana-

-Aetna-

Treatment of Tinnitus

-FloridaBlue-

Ultrasonic

Surgery for Meniere's Syndrome

Vestibular Rehabilitation

Voice

Therapy

-FloridaBlue-

Medicare

Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)

Chelation Therapy - Deferoxamine Mesylate (Desferal)

Chelation Therapy - Dimercaprol (BAL)

Fecal Bacteriotherapy

-Humana-

Fecal Microbiota Transplantation FMT

Gastric Pacing, Enterra Therapy

-FloridaBlue-

Levator Syndrome Treatment

Transanal Radiofrequency Therapy as a Treatment of Fecal Incontinence

-FloridaBlue-

Frequency of Hemodialysis Services

-Medicare-

Out-of-Network Outpatient Dialysis at In-Network Level of Benefits

Percutaneous Tibial Nerve Stimulation

Peritoneal Dialysis

Sacral

Nerve Stimulation

Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia & beta-Thalassemia

Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)

Chelation Therapy - Deferoxamine Mesylate (Desferal)

Chelation Therapy - Dimercaprol (BAL)

COVID-19 Convalescent Plasma

Low Density Lipoprotein (LDL) Apheresis

-Cigna-

Plasmapheresis

Therapeutic Phlebotomy

-FloridaBlue-

-Humana-

Acute Inpatient Rehabilitation

Axial/Spinal Decompression Therapy/Mechanical Traction (Provided in a Clinic Setting)

-Cigna-

Chiropractic Services

-Humana-

Constraint-Induced Therapy

-Aetna-

Fluidized Therapy (Fluidotherapy)

-Aetna-

Mechanical Stretching Devices for Joint Stiffness & Contracture

-FloridaBlue-

Osteopathic Manipulative Treatment

Occupational Therapy

-Aetna-

-UHC-

Therapy & Rehabilitation Services

Physical Therapy

-Aetna-

Physical Therapy & Occupational Therapy

Range of Motion Testing

-Humana-

-Cigna-

Strapping

Treatment of Autism Spectrum Disorders

-FloridaBlue-

Unna

Boot

Electrical Stimulation for the Treatment of Arthritis

Suit Therapy

-Aetna-

Warming Therapy & Ultrasound Therapy for Wounds

-UHC-

Epilepsy Surgery

-Aetna-

Ketogenic Diet for Treatment of Intractable Seizures

Monoclonal Antibody Therapies for Migraine Prevention

-Aetna-

Neurological & Brain Injury Life Skills & Rehabilitation

Speech Language Pathology (SLP) Services: Communication Disorders

Subacute Inpatient Rehabilitation

Spinal Cord Injury Inpatient Rehabilitation

TBI Inpatient Rehabilitation

Vagus Nerve Stimulation for Epilepsy

Applied Behavioral Analysis (ABA)

Attention Deficit Hyperactivity Disorder Assessment & Treatment

-Humana-

Screening for Autism Spectrum Disorders & Rett Syndrome

Behavioral Health Coaching & Peer Support Services

-Cigna-

Behavioral Health Observation Treatment Pathway

Biofeedback

-Aetna-

-Anthem-

-Humana-

Biofeedback for Chronic Pain

Cognitive Rehabilitation

-FloridaBlue-

-Anthem-

Electro-convulsive Therapy (ECT)

Family Psychotherapy

-Aetna-

-UHC-

Group Psychotherapy

Health & Behavior Assessment

Intervention

Inpatient Treatment for Substance-Related & Addictive Disorder Treatment

Inpatient Adult Psychiatry-

Treatment Days 1-6

Inpatient Adult Psychiatry-

Treatment Days 7-13

Inpatient Withdrawal Management (Detoxification)

Intensive In-home Behavioral Health Services

-Aetna-

Intensive Outpatient Program Substance-Related & Addictive Disorder Treatment

Interactive Complexity Services

Low Intensity Residential Clinical Services for Substance-Related & Addictive Disorder Treatment

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS161v10)

Methadone Treatment for Opiate Addiction

Observation Status Adult Psychiatry

Outpatient (Office Based) Medication Assisted Treatment (MAT) Opioid Use Disorder

Outpatient Treatment of Substance-Related & Addictive

Disorder Treatment

Partial Hospitalization Program Substance-Related & Addictive

Disorder Treatment

Partial Hospitalization Program: Adult Psychiatry

Partial Hospitalization Programs

Phototherapy for Psychiatric Disorders

-Aetna-

Psychiatric Diagnostic Evaluation

Psychiatric Inpatient Hospitalization

Psychiatric Rehabilitation Program- Adult

-Maryland-

Psychoanalysis

Psychological & Neuropsychological Tests

Psychotherapy

Psychosocial Rehabilitation Services

Psychotherapy for Crisis

Residential Treatment Center for Substance-Related Addictive Disorder Treatment

Residential Treatment Center with 24-Hour Nursing for Substance-Related & Addictive

Disorder Treatment

Residential Withdrawal Management (Detoxification)

Substance-Related & Addictive

Disorder Treatment - Detoxification

Substance-Related & Addictive

Disorder Treatment - Rehabilitation

Substance-Related Outpatient Withdrawal (Detoxification) with Extended On-Site Monitoring

Substance-Related Outpatient Withdrawal (Detoxification) without Extended On-Site Monitoring

Targeted Case Management

Transcranial Magnetic Stimulation (TMS)

Diagnostic

Aerosol or Vapor Inhalation

Electrical Stimulators - Diaphragmatic/Phrenic Nerve, Functional and Neuromuscular

-Humana-

Noninvasive Home Ventilator Therapy for Respiratory Failure

Obstructive

Sleep Apnea Treatment

Phrenic (Diaphragmatic) Nerve Stimulation

-Cigna-

-FloridaBlue-

Pulmonary Rehabilitation

Respiratory Therapeutic Services

Accelerated Partial Breast Irradiation

(APBI)

Accelerated Breast Irradiation & Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer

Brachytherapy-Oncologic Applications

Brachytherapy

-Humana-

-FloridaBlue-

Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

Chemotherapy Observation or Inpatient Hospitalization

Cranial Stereotactic Radiosurgery (SRS) & Cranial Stereotactic Radiotherapy (SRT)

-UHC-

Electric Tumor Treatment

Field Therapy

Endobronchial Brachytherapy

Fractionation, Image-Guidance, & Special Services

Image-Guided Radiation Therapy

-FloridaBlue

-UHC-

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors

Inpatient Admission for Radiation Therapy

-Cigna-

-UHC-

Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer

Intensity-Modulated Radiation Therapy (IMRT): Abdomen & Pelvis

-Anthem-

Intensity-Modulated Radiotherapy of the Breast & Lung

Intensity Modulated Radiation Therapy (IMRT)

-FloridaBlue-

-Humana-

Intensity-Modulated Radiotherapy of the Prostate

Hyperthermia (deep, intracavitary, whole body) for Cancer Therapy

Hyperthermia (superficial external, interstitial) for Cancer Therapy

Hyperthermia Treatment for Cancer (Local, Regional & Whole Body)

-Humana-

Hyperthermic intraperitoneal chemotherapy (HIPEC)

-FloridaBlue

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors

-UHC-

Inpatient Admission for Radiation Therapy

Intensity Modulated Radiation Therapy (IMRT)

-Humana-

-Cigna-

Intraoperative Radiation

Therapy

Isolated Limb Perfusion/Infusion for Malignant Melanoma

Oncologic Applications of Photodynamic Therapy

-Aetna-

Proton Beam Radiotherapy

(CNS & Axial Skeleton)

Microwave Thermotherapy

-FloridaBlue-

Proton Beam Radiotherapy ( Non CNS )

-Humana-

Radiation Therapy for T1 Basal Cell & Squamous Cell Carcinomas of the Skin

-United-

Radiation Therapy: Fractionation, Image-Guidance, & Special Services

Radioembol-ization for Primary & Metastatic Tumors of the Liver

-UHC-

Selective Internal Radiation Therapy (SIRT) for Primary & Secondary Hepatic Malignancy (Yttrium-90 -Microsphere Hepatic Brachytherapy)

Stereotactic Radiosurgery (SRS) & Stereotactic Body Radiation Therapy

(SBRT)

-FloridaBlue-

-Humana-

-United-

-FloridaBlue

Stereotactic Radiosurgery (Intracranial)

Radio-frequency Tumor Ablation

-FloridaBlue-

-Aetna-

Tumor Treatment Fields (TTF) Therapy for Glioblastoma

Whole Brain Radiotherapy (WBRT)

-FloridaBlue-

Actinic

Keratosis

Allergen Immunotherapy

Allergy

Testing

Eye

Allergy Testing: Patch Testing

Allergy Testing In Vivo (Skin Tests)

Allergy Treatments

-Humana-

Electrical Stimulation (ES) & Electromagn-etic Therapy for the Treatment of Wounds

EpiFix Wound Treatment

-Humana-

Lymphedema & Venous Stasis Ulcer Treatments

Complex Lymphedema Therapy (Complete Decongestive Therapy)

-Cigna-

Lymphedema- Diagnosis & Treatment

-Humana-

Phototherapy & Photochemo-therapy (PUVA) for Skin Conditions

-Aetna-

Targeted Phototherapy & Psoralen with Ultraviolet A for Vitiligo

Topical Photosensitizers used with PDT for Actinic Keratoses

& Certain Skin Cancers

Treatment of Decubitus Ulcers

Wound

Care

Allergy Immunotherapy

Ambulance Services

Air & Water

Ambulance Services

Non-emergency Ground

Ancillary Services for Pregnancy Complications

Aquatic

Therapy

Art Therapy

-Aetna-

Cold Therapy Devices/Heating Devices/Combined Heat & Cold Therapy Devices

-Humana-

Donor Human Milk

Electric Stimulation for Pain, Swelling & Function in a Clinic Setting

-Anthem-

-Cigna-

Electrical Stimulators for Pain & Nausea/Vomiting

Electrical Stimulation for the Treatment of Pain & Muscle Rehabilitation

-Humana-

-UHC-

Equine-assisted Therapy for Behavioral Health

Eye Movement Desensitization &

Reprocessing (EMDR)

Home Health Aides

Home Phototherapy Devices for Neonatal Hyperbilirubinemia

-Aetna-

Hydration Therapy

Hyperbaric & Topical Oxygen Therapies

-Aetna-

-Anthem-

-Cigna-

-Humana-

-Medicare-

Inpatient Subacute Care

Intestinal Rehabilitation Programs

-Aetna-

Iontophoresis

Long Term Care Hospitals (LTCH)

-Cigna-

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

-FloridaBlue-

-Humana-

Manipulative Therapy

Medical

Maggots

Medicinal Leech Therapy

Bio-Surgery Medicinal Leech Therapy & Medical Maggots

Neonatal Level of Care

-Aetna-

Non-pharmacologic Treatments for Chronic

Vertigo

Observation Room Services

Observation vs. Admission Criteria Making for the Treatment of Emergency Room Conditions

Outpatient Skilled Nursing & Skilled Rehabilitation Services

Outpatient Use of Arixtra, Direct Thrombin Inhibitors, and Low Molecular Weight Heparin (LMWH)

Parenteral Drug Administration & In-Office Dispensing of Medications

Pet

Therapy

Pritikin Program

Private Duty Nursing in the Home Setting

Skilled Home Health Care Nursing Services

-Aetna-

Skilled Nursing Facility Services

Special Treatment Procedure & Special Physics Consult

-FloridaBlue

Platelet-Derived Growth Factors for Wound Healing

Transcatheter Infusion

Therapy

-Humana-

Adoptive Immunotherapy

-Cigna-

-FloridaBlue-

Autologous Cell-Based Therapy for Cardiac and Peripheral Arterial Disease

-Cigna-

Auditory & Sensory Integration Training Therapy (AIT)

Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP])

-Cigna-

-FloridaBlue-

Biomagnetic Therapy

Bronchial Thermoplasty

-Anthem-

-Cigna-

-FloridaBlue-

Carotid Intima-Media Thickness Measurement

Custodial & Non-Skilled Services

-Cigna-

Exhaled Nitric Oxide & Exhaled Breath Condensate in the Management of Respiratory

Disorders

Headache & Occipital Neuralgia Treatment

-Cigna-

High-Frequency Pulsed Electromagnetic Stimulation

Hippotherapy

-Aetna-

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

Neutron Beam Radiotherapy

-Anthem-

-Cigna-

Rehabilitative Devices with Remote Monitoring

-Anthem-

Ultrasound Therapy for Wound Healing

Virtual Reality-Assisted Therapy Systems

-Humana-

-Anthem-

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