Therapeutics-07

Therapeutics

Select System

Indicates Non-Covered Service

Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)

-FloridaBlue-

Chelation Therapy - Deferoxamine Mesylate (Desferal)

Chelation Therapy - Dimercaprol (BAL)

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

Allogeneic Hematopoietic Cell Transplantation

-FloridaBlue-

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

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

Stem Cell Transplantation: Blood Cancers

-Cigna-

Thymus Tissue Transplantation

-Anthem-

Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation

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

Education & Diabetic Management During

Ramadan

Diabetic Pharmacological 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 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

Healthy Weight & Eating Well with Diabetes

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

Treatment of Tinnitus

-FloridaBlue-

Ultrasonic

Surgery for Meniere's Syndrome

Vestibular Rehabilitation

-FloridaBlue-

Voice

Therapy

-Aetna-

-Medicare-

Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)

Chelation Therapy - Deferoxamine Mesylate (Desferal)

Chelation Therapy - Dimercaprl (BAL)

Fecal Bacteriotherapy

-Humana-

Fecal Microbiota Transplantation FMT

-FloridaBlue-

Gastric Pacing, Enterra Therapy

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

-Cigna-

Low Density Lipoprotein (LDL) Apheresis

Plasmapheresis

-FloridaBlue-

-Humana-

Acute Inpatient Rehabilitation

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

Chiropractic Services

-Humana-

Constraint-Induced Therapy

-Aetna-

Fluidized Therapy (Fluidotherapy)

-Aetna-

Mechanical Stretching Devices for Joint Stiffness & Contracture

-FloridaBlue-

Osteopathic Manipulative Treatment

-UHC-

Occupational Therapy

-Aetna-

Therapy & Rehabilitation Services

Physical Therapy

-Aetna-

Physical Therapy & Occupational Therapy

Range of Motion Testing

Strapping

Treatment of Autism Spectrum Disorders

-Humana-

-Cigna-

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

-Aetna-

Monoclonal Antibody Therapies for Migraine Prevention

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

Screening for Autism Spectrum Disorders & Rett Syndrome

Behavioral Health Coaching & Peer Support Services

Behavioral Health Observation Treatment Pathway

Biofeedback

-Aetna-

-Anthem-

Biofeedback for Chronic Pain

-Anthem-

-Humana-

Cognitive Rehabilitation

-FloridaBlue-

Electro-convulsive Therapy (ECT)

-Aetna-

Family Psychotherapy

Group Psychotherapy

Health & Behavior Assessment Intervention

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 Program: Psychiatric Care

Phototherapy for Psychiatric Disorders

-Aetna-

Psychiatric Diagnostic Evaluation

Psychiatric Inpatient Hospitalization

Psychiatric Rehabilitation Program- Adult

Psychoanalysis

Psychological & Neuropsychological Tests

Psychosocial Rehabilitation Services

Psychotherapy

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

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

Noninvasive Home Ventilator Therapy for Respiratory Failure

Obstructive

Sleep Apnea Treatment

Phrenic (Diaphragmatic) Nerve Stimulation

-Cigna-

Pulmonary Rehabilitation

Respiratory Therapeutic Services

-Humana-

-FloridaBlue-

Accelerated Partial Breast Irradiation

(APBI)

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

Brachytherapy-Oncologic Applications

-FloridaBlue-

Brachytherapy

-Humana-

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

Chemotherapy Observation or Inpatient Hospitalization

-UHC-

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

Electric Tumor Treatment

Field Therapy

Endobronchial Brachytherapy

Fractionation, Image-Guidance, & Special Services

-FloridaBlue-

High-Dose Rate Temporary Prostate Brachytherapy

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-

Image-Guided Radiation Therapy

-FloridaBlue-

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors

-UHC-

Inpatient Admission for Radiation Therapy

-Cigna-

Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer

-Anthem-

Intensity Modulated Radiation Therapy (IMRT)

-FloridaBlue-

-Humana-

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

Intensity-Modulated Radiotherapy of the Breast & Lung

Intensity-Modulated Radiotherapy: Central Nervous System Tumors

Intensity-Modulated Radiotherapy: Cancer of the Head & Neck or Thyroid

Intensity-Modulated Radiotherapy of the Prostate

Intraoperative Radiation

Therapy

Isolated Limb Perfusion/Infusion for Malignant Melanoma

Microwave Thermotherapy

Oncologic Applications of Photodynamic Therapy

-Aetna-

Proton Beam Radiotherapy

(CNS & Axial Skeleton)

-FloridaBlue-

Proton Beam Radiotherapy ( Non CNS )

Proton & Neutron Beam Radiation Therapy

-Humana-

-United-

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

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

Radioembol-ization for Primary & Metastatic Tumors of the Liver

Radio-frequency Tumor Ablation

-Aetna-

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-

Stereotactic Radiosurgery (Intracranial)

-FloridaBlue-

Tumor Treatment Fields (TTF) Therapy for Glioblastoma

-FloridaBlue-

Whole Brain Radiotherapy (WBRT)

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

Lymphedema & Venous Stasis Ulcer Treatments

Complex Lymphedema Therapy (Complete Decongestive Therapy)

Lymphedema- Diagnosis & Treatment

-Humana-

Phototherapy & Photochemo-therapy (PUVA) for Skin Conditions

Targeted Phototherapy & Psoralen with Ultraviolet A for Vitiligo

-Aetna-

-Cigna-

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

-Aetna-

Art Therapy

Brachytherapy

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

Donor Human Milk

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

Electrical Stimulators for Pain & Nausea/Vomiting

-Humana-

Electrical Stimulation for the Treatment of Pain & Muscle Rehabilitation

-UHC-

Equine-assisted Therapy for Behavioral Health

-Humana-

-Cigna-

Eye Movement Desensitization &

Reprocessing (EMDR)

Home Health Aides

-Aetna-

Home Phototherapy Devices for Neonatal Hyperbilirubinemia

Hydration Therapy

Hyperbaric & Topical Oxygen Therapies

Iontophoresis

Inpatient Subacute Care

Intestinal Rehabilitation Programs

-Aetna-

Long Term Care Hospitals (LTCH)

-Cigna-

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

Manipulative Therapy

Medical

Maggots

Medicinal Leech Therapy

Neonatal Level of Care

Non-pharmacologic Treatments for Chronic

Vertigo

Outpatient Skilled Nursing & Skilled Rehabilitation Services

Observation Room Services

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

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

Parenteral Drug Administration & In-Office Dispensing of Medications

Pet

Therapy

Platelet-Derived Growth Factors for Wound Healing

-Humana-

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

Transcatheter Infusion

Therapy

Adoptive Immunotherapy

-Cigna-

-FloridaBlue-

Auditory & Sensory Integration Training Therapy (AIT)

Autologous Cell-Based Therapy for Cardiac and Peripheral Arterial Disease

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

Biomagnetic Therapy

-Anthem-

Bronchial Thermoplasty

-Cigna-

-FloridaBlue-

Carotid Intima-Media Thickness Measurement

-Cigna-

-FloridaBlue-

-Cigna-

Custodial & Non-Skilled Services

-Cigna-

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

Disorders

Headache & Occipital Neuralgia Treatment

-Cigna-

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

-Cigna-

High-Frequency Pulsed Electromagnetic Stimulation

-Aetna-

Hippotherapy

-Aetna-

Neutron Beam Radiotherapy

-Anthem-

-Cigna-

Rehabilitative Devices with Remote Monitoring

-Anthem-

Ultrasound Therapy for Wound Healing

-Humana-

Virtual Reality-Assisted Therapy Systems

-Anthem-

420, 421, 422, 423, 424, 429, 430, 431, 432, 433, 434, 439, 440, 441, 442, 443, 444,, 449, 90875, 90876, 90901, 90912, 90913, 92507, 92508, 92520, 92526, 92606, 92609, 92630, 92633, 97010, 97012, 97014,97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036,, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150,,97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755,, 97760, 97761, 97763, 97799, G0129, G0283, S9152, V5362, V5363, V5364, 90889, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T, H0031, H0032, H2012, H2019, 912, 913, 915, 90867, 90868, 90869, K1002, 98940, 98941, 98942, 98943, 43647, 43648, 43881, 43882, 64590, 99183, G0277, , 32701, 61796, 61798, 63620, 77371, 77372, 77373, 77385, 77386, 77401, 77402, 77407, 77412, 77423, 77424, 77425, 77520, 77522, 77523, 77525, 77750, 77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, G0339, G0340, G0458, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, 420, 421, 422, 423, 424, 429, 430, 431, 432, 433, 434, 439, 440, 441, 442, 443, 444, 449, 92507, 92508, 92520, 92526, 92606, 92609, 92630, 92633, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97763, 97799, G0129, G0283, S9152, V5362, V5363, V5364, , 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165,