UHC

ACG-UHC Demonstration Project

17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P)

Ablative Treatment for Spinal Pain

Abnormal Uterine Bleeding & Uterine Fibroids

Actemra® (Tocilizumab) Injection for Intravenous Infusion

Alpha1-Proteinase Inhibitors

Ambulance Services

Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and Methoxy Polyethylene Glycol-Epoetin Beta

Apheresis

Athletic Pubalgia Surgery

Attended Polysomnography for Evaluation of Sleep Disorders

Autologous Chondrocyte Transplantation in the Knee

Balloon Sinus Ostial Dilation

Bariatric

Surgery

Bariatric

Surgery

Maryland

Benlysta® (Belimumab)

Blepharoplasty, Blepharoptosis

& Brow Ptosis Repair

Bone or Soft Tissue Healing & Fusion Enhancement Products

Botulinum

Toxins A & B

Breast Imaging for Screening & Diagnosing Cancer

Breast Reconstruction Post Mastectomy

Breast

Reduction Surgery

Breast Repair/Reconstruction Not Following Mastectomy

Brineura™ (Cerliponase

Alfa)

Bronchial Thermoplasty

Buprenorphine (Probuphine® & Sublocade™)

Cardiovascular Disease Risk Tests

Carrier Testing for Genetic Diseases

Chemosensitivity & Chemoresistance Assays in Cancer

Chemotherapy Observation or Inpatient Hospitalization

Chromosome 1p/19q Deletion Analysis

Chromosome Microarray Testing

Clinical

Trials

Clotting Factors & Coagulant Blood Products

Cochlear Implants

Cognitive Rehabilitation

Collagen Crosslinks & Biochemical Markers of Bone Turnover

Computed Tomographic Colonography

Computerized Dynamic Posturography

Continuous Glucose Monitoring & Insulin Delivery for Managing Diabetes

Core Decompression

for Avascular Necrosis

Corneal Hysteresis & Intraocular Pressure Measurement

Cosmetic & Reconstructive Procedures

Crysvita (burosumab-twza)

Cytological Examination of Breast Fluids for Cancer Screening

Deep Brain & Cortical Stimulation

Denosumab (Prolia® & Xgeva®)

Discogenic

Pain

Treatment

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies & Repairs/Replacements

Elbow Replacement Surgery (Arthroplasty)

Electric Tumor Treatment

Field Therapy

Electrical & Ultrasound Bone Growth Stimulators

Electrical Bioimpedance for Cardiac Output Measurement

Electrical Stimulation & Electromagnetic Therapy for Wounds

Electrical Stimulation for the Treatment of Pain & Muscle Rehabilitation

Embolization of Ovarian & Iliac Veins for Pelvic Congestion Syndrome

Emergency Health Care Services & Urgent Care Center Services

Entyvio® (Vedolizumab)

Enzyme Replacement Therapy

Epidural Steroid & Facet Injections for Spinal Pain

Epiduroscopy, Epidural Lysis of Adhesions

& Functional Anesthetic Discography

Erythropoiesis Stimulating Agents (ESA)

Exondys 51™ (Eteplirsen)

Extracorporeal Shock Wave Therapy (ESWT)

Fecal

Calprotectin Testing

Femoroacetabular Impingement Syndrome

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Functional Endoscopic Sinus Surgery (FESS)

Gait Analysis

Gastrointestinal Motility Disorders, Diagnosis & Treatment

Gender Dysphoria Treatment

Gene Expression Tests for Cardiac Indications

Genetic Testing for Hereditary Cancer

Glaucoma

Surgical Treatments

Gonadotropin Releasing Hormone Analogs

Gynecomastia Treatment

Habilitative Services for Essential Health Groups

Hearing Aids & Devices Including Wearable, Bone-Anchored & Semi-Implantable

Hepatitis Screening

Hereditary Angioedema (HAE), Treatment & Prophylaxis

High Frequency Chest Wall Compression Devices

Hip Resurfacing

& Replacement Surgery (Arthroplasty)

Home

Health

Care

Home Hemodialysis

Traction

Hospital Readmissions

Hysterectomy for Benign Conditions

Ilaris® (Canakinumab)

Ilumya (TILDRAKIZUMAB-ASMN)

Immune Globulin

(IVIG & SCIG)

Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors

Implanted Electrical Stimulator for Spinal Cord

Infertility Diagnosis & Treatment

Infertility Services

Infliximab (Remicade®, Inflectra™, Renflexis™)

Inpatient Pediatric Feeding Programs

Intensity-Modulated Radiation Therapy

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Intrauterine Fetal Surgery

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

Ketamine

Laser Interstitial Thermal Therapy

Lemtrada (Alemtuzumab)

Light & Laser Therapy for Cutaneous Lesions & Pilonidal Disease

Lithotripsy for Salivary Stones

Luxturna™ (Voretigene Neparvovec-Rzyl)

Macular Degeneration Treatment Procedures

Magnetic Resonance Spectroscopy (MRS)

Manipulation Under Anesthesia

Manipulative Therapy

Mechanical Stretching Devices

Meniscus

Implant & Allograft

Mifeprex® (Mifepristone)

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD)

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, & Treatment Decisions

Nerve Graft to Restore Erectile Function During Radical Prostatectomy

Neurophysiologic Testing &

Monitoring

Neuropsychological Testing Under the Medical Benefit

Obstructive

Sleep Apnea Treatment

Occipital Neuralgia & Headache Treatment

Ocrevus™ (Ocrelizumab)

Off-Label/Unproven Specialty Drug Treatment

Office Based Program

Omnibus Codes

Oncology Medication Clinical Coverage

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors

Orencia® (Abatacept) Injection for Intravenous Infusion

Orthognathic

(Jaw)

Surgery

Osteochondral Grafting

Outpatient Cardiac Telemetry

Outpatient Skilled Nursing & Skilled Rehabilitation Services

Panniculectomy & Body Contouring Procedures

Parsabiv (etelcalcetide)

Pectus Deformity

Repair

Percutaneous Vertebroplasty & Kyphoplasty

Pharmacogenetic Testing

Plagiocephaly & Craniosynostosis Treatment

Platelet Derived Growth Factors for Treatment of Wounds

Pneumatic Compression Devices

Preterm

Labor Management

Preventive Care Services

Private Duty Nursing Services (PDN)

Prolotherapy for Musculoskeletal Indications

Propranolol Treatment for Infantile Hemangiomas: Inpatient Protocol

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs

Proton Beam Radiation Therapy

Radicava™ (Edaravone)

Rehabilitation Services (Outpatient)

Repository Corticotropin Injection (H.P. Acthar Gel®)

Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®)

Review at Launch for New to Market Medications

Rhinoplasty & Other Nasal Surgeries

Rituxan® (Rituximab)

Self-administered Medications

Shoulder Replacement Surgery Arthroplasty

Simponi Aria® (Golimumab) Injection for Intravenous Infusion

Site of Service for Certain Outpatient Surgical Procedures

Skilled Care & Custodial Care Services

Sodium Hyaluronate

Soliris® (Eculizumab)

Somatostatin Analogs

Specialty Medication Administration

Speech Language Pathology Services

Spinal Ultrasonography

Spinraza™ (Nusinersen)

Stelara® (Ustekinumab)

Surgical & Ablative Procedures for Venous Insufficiency & Varicose Veins

Surgical Treatment for Spine Pain

Synagis® (Palivizumab)

Tempomandibular Joint Disorders

Thermal Capsulorrhaphy/Thermal Shrinkage Therapy

Thermography

Total Artificial Disc Replacement for the Spine

Total

Artificial Heart

Total Knee Replacement Surgery (Arthroplasty)

Transcatheter Heart Valve Procedures

Transcranial Magnetic Stimulation (TMS)

Transpupillary Thermotherapy

Trogarzo (ibalizumab-

uiyk)

Umbilical Cord Blood Harvesting

& Storage for Future Use

Unicondylar Spacer Devices for Treatment of

Pain/Disability

Vaccines

Vagus Nerve Stimulation

Virtual Upper Gastrointestinal Endoscopy

Visual Information Processing Evaluation & Orthoptic & Vision Therapy

Warming Therapy & Ultrasound Therapy for Wounds

White Blood Cell Colony Stimulating Factors

Whole Exome & Whole Genome Sequencing

Xolair® (Omalizumab)