Fecha de vigencia | Policy Name | Reviewed Date |
8/25/2022 |
Ablation Techniques and Extracorporeal Shock Wave Therapy for Musculoskeletal Indications and Soft Tissue Wounds
| 8/25/2022 |
5/25/2023 |
Tratamientos para acalasia y enfermedad de reflujo gastroesofágico (ERGE)

| 5/25/2023 |
3/13/2023 |
Acne Treatments
| 2/2/2023 |
9/22/2022 |
Actinic Keratoses Treatments
| 9/22/2022 |
12/8/2022 |
Acupuntura
| 12/8/2022 |
4/27/2023 |
Ambulancia aérea
| 4/27/2023 |
3/1/2023 |
Airway Clearance Devices
| 3/1/2023 |
3/1/2023 |
Pruebas para la alergia
| 3/1/2023 |
9/22/2022 |
Tratamientos para la alergia
| 9/22/2022 |
2/2/2023 |
Allograft Transplantation of the Knee
| 2/2/2023 |
3/23/2023 |
Dispositivos de monitoreo cardiaco ambulatorio
| 3/23/2023 |
3/1/2023 |
Applied Behavior Analysis
| 3/1/2023 |
3/23/2023 |
Reemplazo artificial de disco intervertebral
| 3/23/2023 |
3/23/2023 |
Athletic Pubalgia Surgery
| 3/23/2023 |
2/13/2023 |
Trastorno por déficit de atención con hiperactividad (ADHD) - Diagnóstico y tratamiento
| 6/23/2022 |
1/1/2021 |
Auryxia (ferric citrate)
| 3/15/2023 |
3/1/2023 |
Autism Spectrum Disorders Diagnosis and Treatment
| 3/1/2023 |
5/25/2023 |
Autologous and Allogeneic Bone Marrow Transplants

| 5/25/2023 |
2/2/2023 |
Autonomic Nerve Function Testing
| 2/2/2023 |
4/27/2023 |
Balloon Dilation (Eustachian Tube and Sinus), Functional Endoscopic Sinus Surgery and RhinAer
| 4/27/2023 |
3/1/2023 |
Cirugía bariátrica
| 3/1/2023 |
3/1/2023 |
Benign Prostatic Hyperplasia Treatments
| 3/1/2023 |
6/23/2022 |
Benign Skin Lesion Treatments
| 6/23/2022 |
12/8/2022 |
Bioretroalimentación
| 12/8/2022 |
4/27/2023 |
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
| 4/27/2023 |
5/25/2023 |
Medición de densidad ósea
| 5/25/2023 |
3/1/2023 |
Sustitutos de injerto óseo
| 3/1/2023 |
2/27/2023 |
Estimuladores para el crecimiento de los huesos
| 2/2/2023 |
5/25/2023 |
Braquiterapia

| 5/25/2023 |
8/25/2022 |
Breast Imaging
| 8/25/2022 |
5/25/2023 |
Reconstrucción de mama

| 5/25/2023 |
5/26/2022 |
Bronchial Thermoplasty
| 5/26/2022 |
5/25/2023 |
Tratamientos quirúrgicos para juanetes y juanetes de sastre

| 5/25/2023 |
1/1/2021 |
Calcitonin gene_related peptide (CGRP) inhibitors

| 5/18/2023 |
9/1/2022 |
Calcitonin gene_related peptide (CGRP) inhibitors

| 5/18/2023 |
1/1/2023 |
Endoscopía capsular
| 8/25/2022 |
3/1/2023 |
Cateterización cardíaca
| 3/1/2023 |
5/25/2023 |
Estudios electrofisiológicos cardíacos y ablación cardíaca por catéter

| 4/27/2023 |
9/22/2022 |
Rehabilitación cardíaca
| 9/22/2022 |
8/25/2022 |
Cardiac Single Photon Emission Computed Tomography
| 8/25/2022 |
3/23/2023 |
Cardiovascular Disease Risk Testing
| 10/27/2022 |
3/1/2023 |
Desfibriladores cardioversores/terapia de resincronización cardíaca
| 3/1/2023 |
10/27/2022 |
Revascularización de la arteria carótida
| 10/27/2022 |
9/22/2022 |
Carpal Tunnel Syndrome Surgical Treatments
| 9/22/2022 |
7/27/2022 |
Atención quiropráctica
| 7/27/2022 |
9/22/2022 |
Chronic Vertigo Evaluation and Treatment
| 9/22/2022 |
9/22/2022 |
Ensayos clínicos
| 9/22/2022 |
2/2/2023 |
Code Compendium (Cardiovascular)
| 2/2/2023 |
4/27/2023 |
Compendio de códigos (laboratorio)
| 4/27/2023 |
3/23/2023 |
Compendio del código (misceláneo)
| 3/23/2023 |
2/2/2023 |
Compendio de códigos (musculosqueléticos y neurológicos)
| 2/2/2023 |
2/2/2023 |
Code Compendium (Obstetrics -Gynecology)
| 2/2/2023 |
2/2/2023 |
Compendio del código (oftalmología)
| 2/2/2023 |
2/2/2023 |
Code Compendium (Wound Care)
| 9/22/2022 |
4/27/2023 |
Rehabilitación congnitiva
| 4/27/2023 |
9/22/2022 |
Cold Therapy Devices/ Heating Devices/ Combined Heat and Cold Therapy Devices
| 9/22/2022 |
12/8/2022 |
Colorectal Cancer Screening and Surveillance
| 12/8/2022 |
10/27/2022 |
Comparative Genomic Hybridization/Chromosomal Microarray
| 10/27/2022 |
8/25/2022 |
Medicina complementaria y alternativa
| 8/25/2022 |
4/1/2023 |
Comprehensive Molecular Profiling for Hematologic Malignancies and Solid Tumors
| 6/23/2022 |
8/25/2022 |
Concurrent DNA and RNA Genetic Testing
| 8/25/2022 |
8/25/2022 |
Control ambulatorio continuo de presión arterial
| 8/25/2022 |
4/27/2023 |
Continuous Glucose Monitoring Systems and Insulin Pumps
| 4/27/2023 |
2/2/2023 |
Continuous Passive Motion and Mechanical Stretching Devices
| 2/2/2023 |
2/2/2023 |
Coronary CT Angiography, Fractional Flow Reserve with CT, Calcium Scoring
| 2/2/2023 |
5/25/2023 |
Coronary Stents and Angioplasty

| 5/25/2023 |
9/22/2022 |
Cosmetic and Reconstructive Surgery
| 9/22/2022 |
12/8/2022 |
Cryoablation
| 12/8/2022 |
1/1/2023 |
Deep Brain Stimulation and Cortical Brain Stimulation
| 5/26/2022 |
4/27/2023 |
Diagnostic Esophagogastroduodenoscopy or Esophagascopy (age 59 years or younger)
| 4/27/2023 |
4/1/2023 |
Digital Therapeutics
| 3/1/2023 |
3/1/2023 |
Discograma
| 3/1/2023 |
9/22/2022 |
Análisis
| 9/22/2022 |
3/23/2023 |
Equipo médico duradero
| 2/2/2023 |
6/1/2023 |
Equipo médico duradero

| 2/2/2023 |
6/23/2022 |
Dynamic Spinal Stabilization Devices
| 6/23/2022 |
2/2/2023 |
Cirugía electiva de reparación de aneurisma de aorta y arteria ilíaca
| 10/27/2022 |
2/2/2023 |
Campos eléctricos para el tratamiento de tumores
| 2/2/2023 |
3/23/2023 |
Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds
| 3/23/2023 |
4/1/2023 |
Estimuladores eléctricos - Nervio frénico/del diafragma, funcionales y neuromusculares
| 7/27/2022 |
4/27/2023 |
Electrical Stimulators for Pain and Nausea/Vomiting
| 4/27/2023 |
12/8/2022 |
Electrothermal Intradiscal Therapies
| 12/8/2022 |
2/2/2023 |
Emerging Tumor Markers for Diagnosis and Monitoring of Cancer
| 2/2/2023 |
8/25/2022 |
Endobronchial Valves for the Treatment of Severe Emphysema
| 8/25/2022 |
3/1/2023 |
Erectile Dysfunction and Peyronie's Disease Treatments
| 3/1/2023 |
4/28/2022 |
Exhaled Breath Tests
| 4/28/2022 |
12/8/2022 |
Oftalmoscopía extendida
| 12/8/2022 |
3/1/2023 |
Extraosseous Subtalar Joint implantation and Subtalar Arthroereisis
| 3/1/2023 |
12/8/2022 |
Fecal Incontinence Evaluation and Treatments
| 12/8/2022 |
1/1/2023 |
Fecal Microbiota Transplantation
| 7/27/2022 |
12/1/2022 |
Diagnóstico de fusión de imágenes
| 7/27/2022 |
3/23/2023 |
Gastric Pacing-Gastric Electrical Stimulation
| 3/23/2023 |
3/23/2023 |
Gastrointestinal Motility Monitoring
| 3/23/2023 |
9/22/2022 |
Gender Affirmation Surgery
| 9/22/2022 |
4/27/2023 |
Gene Expression Profiling for Cancer Indications
| 4/27/2023 |
4/27/2023 |
Gene Expression Profiling for Noncancer Indications
| 4/27/2023 |
8/25/2022 |
Gene Expression Profiling for Prostate Cancer
| 8/25/2022 |
1/1/2023 |
Prueba genética o de marcador biológico para la enfermedad de Alzheimer
| 7/27/2022 |
2/2/2023 |
Genetic and Coagulation Testing for Noncancer Blood Disorders
| 8/25/2022 |
3/1/2023 |
Exámenes genéticos
| 3/1/2023 |
10/27/2022 |
Genetic Testing and Liquid Biopsy for Prostate Cancer
| 10/27/2022 |
4/27/2023 |
Genetic Testing for Angelman and Prader-Willi Syndrome
| 4/27/2023 |
3/23/2023 |
Prueba genética de susceptibilidad al cáncer de mama, ovario y páncreas
| 3/23/2023 |
2/2/2023 |
Prueba genética de susceptibilidad al cáncer
| 2/2/2023 |
8/25/2022 |
Prueba genética para afecciones cardíacas
| 8/25/2022 |
12/8/2022 |
Pruebas genéticas para detección de portadores
| 12/8/2022 |
2/2/2023 |
Genetic Testing for Celiac Disease
| 2/2/2023 |
4/27/2023 |
Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
| 4/27/2023 |
2/2/2023 |
Prueba genética de susceptibilidad al cáncer de colon
| 2/2/2023 |
8/25/2022 |
Prueba genética para fibrosis quística
| 8/25/2022 |
5/25/2023 |
Prueba genética para el diagnóstico y monitoreo del cáncer

| 5/25/2023 |
12/8/2022 |
Prueba genética para el diagnóstico de indicaciones no cancerígenas
| 12/8/2022 |
12/8/2022 |
Prueba genética para riesgo de enfermedades
| 9/22/2022 |
3/23/2023 |
Genetic Testing for Ehlers-Danlos Syndrome
| 3/23/2023 |
4/27/2023 |
Pruebas genéticas para detectar ataxia hereditaria
| 6/23/2022 |
3/1/2023 |
Genetic Testing for Marfan Syndrome and Related Conditions
| 3/1/2023 |
3/23/2023 |
Genetic Testing for Methylene Tetrahydrofolate Reductase
| 3/23/2023 |
5/25/2023 |
Pruebas genéticas para detectar distrofia muscular y atrofia muscular espinal
| 5/25/2023 |
12/8/2022 |
Genetic Testing for Niemann-Pick Disease
| 12/8/2022 |
9/22/2022 |
Genetic Testing for RASopathy Syndromes
| 9/22/2022 |
4/27/2023 |
Glaucoma Surgical Treatments
| 4/27/2023 |
3/23/2023 |
Gynecomastia Surgery
| 3/23/2023 |
2/2/2023 |
Hammer Toe Surgical Treatments
| 2/2/2023 |
3/23/2023 |
Tratamientos para la migraña y la neuralgia occipital
| 3/23/2023 |
10/27/2022 |
Artroplastia de cadera
| 10/27/2022 |
12/8/2022 |
Hip, Knee and Shoulder Arthroscopic Surgeries
| 12/8/2022 |
4/27/2023 |
Home Births and Birth Doulas
| 4/27/2023 |
4/1/2023 |
Atención en el hogar
| 6/23/2022 |
5/25/2023 |
Monitoreo de oximetría en el hogar
| 5/25/2023 |
5/25/2023 |
Hyperbaric Oxygen Therapy, Topical Oxygen Therapy

| 5/25/2023 |
4/27/2023 |
Hyperhidrosis Treatments
| 4/27/2023 |
10/27/2022 |
Hyperthermia Treatment for Cancer (Local, Regional and Whole Body)
| 10/27/2022 |
10/27/2022 |
Immunoassay Testing for Rupture of Membranes in Pregnancy
| 10/27/2022 |
2/2/2023 |
Implantable and Non-Implantable Hearing Devices
| 2/2/2023 |
5/25/2023 |
Bombas de infusión implantables para pacientes con dolor o espasmos

| 5/25/2023 |
3/23/2023 |
In Vitro Chemoresistance and Chemosensitivity Assays
| 3/23/2023 |
4/27/2023 |
Infertility Evaluation and Treatment
| 4/27/2023 |
12/8/2022 |
Inhaled Nitric Oxide
| 12/8/2022 |
7/27/2022 |
Inyecciones para afecciones con dolor crónico
| 7/27/2022 |
7/27/2022 |
Intensity Modulated Radiation Therapy
| 7/27/2022 |
8/25/2022 |
Interspinous Process Decompression Spacers
| 8/25/2022 |
7/27/2022 |
Intraocular Lens Implants
| 7/27/2022 |
4/28/2022 |
Intraoperative Neurological Monitoring
| 4/28/2022 |
4/27/2023 |
Irreversible Electroporation (NanoKnife)
| 4/27/2023 |
7/27/2022 |
Janus Kinase 2 (JAK2) V617F, Exon 12 -15, Calreticulin (CALR) and MPL Mutation Analysis
| 7/27/2022 |
5/25/2023 |
Tratamientos quirúrgicos del queratocono

| 5/25/2023 |
8/25/2022 |
Artroplastia de rodilla
| 8/25/2022 |
3/23/2023 |
Laboratorio de análisis para cáncer de próstata
| 7/27/2022 |
7/27/2022 |
Laparoscopic Hiatal Hernia Repair
| 7/27/2022 |
3/1/2023 |
Terapia térmica intersticial con láser
| 3/1/2023 |
5/25/2023 |
Leadless Cardiac Pacemakers

| 5/25/2023 |
1/5/2023 |
Cierre del apéndice auricular izquierdo y defectos estructurales cardíacos para prevenir accidentes cerebrovasculares
| 9/22/2022 |
5/25/2023 |
Biopsia líquida

| 2/2/2023 |
5/25/2023 |
Low Level Laser and High Power Laser Therapy

| 5/25/2023 |
9/22/2022 |
Prueba de detección del cáncer de pulmón
| 9/22/2022 |
5/25/2023 |
Lymphedema (Diagnosis and Treatment)

| 5/25/2023 |
7/27/2022 |
Manipulation Under Anesthesia
| 7/27/2022 |
9/22/2022 |
Microwave Thermotherapy
| 9/22/2022 |
6/23/2022 |
Mobility Assistive Devices (Wheelchairs)
| 6/23/2022 |
3/1/2023 |
Molecular Diagnostic Assays and Breath Testing for Transplant Rejection
| 3/1/2023 |
3/23/2023 |
Molecular Diagnostic Testing for Lyme Disease and other Vector Borne Illness
| 3/23/2023 |
10/1/2022 |
Pruebas moleculares de diagnóstico de salud reproductiva
| 5/26/2022 |
3/1/2023 |
Marcadores moleculares en biopsias con agujas finas de nódulos en la tiroides
| 3/1/2023 |
7/27/2022 |
Molecular Testing for HLA B27 for Ankylosing Spondylitis
| 7/27/2022 |
5/25/2023 |
Multianalyte Assays with Algorithmic Analyses for Cancer Indications

| 5/25/2023 |
5/1/2023 |
Multianalyte Assays with Algorithmic Analyses for Noncancer Indications

| 6/23/2022 |
3/23/2023 |
Multiplex Pathogen Testing and Next Generation Sequencing for Infectious Disease
| 12/8/2022 |
3/23/2023 |
Terapia de presión negativa para heridas
| 3/23/2023 |
3/23/2023 |
Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography
| 3/23/2023 |
10/27/2022 |
Técnicas neuroablativas para el dolor crónico
| 10/27/2022 |
10/27/2022 |
Respiradores no invasivos para el hogar
| 10/27/2022 |
12/8/2022 |
Noninvasive Prenatal Testing
| 12/8/2022 |
2/2/2023 |
Pruebas no invasivas para fibrosis hepática
| 2/2/2023 |
1/1/2016 |
Antihistamínicos no sedantes
| 3/15/2023 |
5/25/2023 |
Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Nonsurgical Treatments

| 5/25/2023 |
1/1/2023 |
Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments
| 7/27/2022 |
12/8/2022 |
Ocular Surface Disease Diagnosis and Treatments
| 12/8/2022 |
3/1/2023 |
Cirugía ortognática
| 3/1/2023 |
3/1/2023 |
Ortopedia
| 3/1/2023 |
12/8/2022 |
Cirugía de defectos osteocondrales y subcondrales
| 12/8/2022 |
10/27/2022 |
Panniculectomy, Abdominoplasty, Abdominal Contouring
| 10/27/2022 |
1/1/2023 |
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty
| 9/22/2022 |
2/2/2023 |
Peripheral Artery Disease of the Lower Extremities Angiography, Screening and Exercise Rehabilitation
| 2/2/2023 |
2/2/2023 |
Peripheral Artery Revascularization of the Lower Extremities
| 2/2/2023 |
4/1/2023 |
Farmacogenómica - Citocromo P450, polimorfismos y VKORC1
| 10/27/2022 |
4/27/2023 |
Pharmacogenomics - Noncancer Indications
| 4/27/2023 |
5/25/2023 |
Farmacogenómica y diagnóstico complementario

| 5/25/2023 |
5/26/2022 |
Physical Therapy (PT) and Occupational Therapy (OT)
| 5/26/2022 |
7/27/2022 |
Tratamientos para fascitis plantar
| 7/27/2022 |
6/23/2022 |
Factor de crecimiento derivado de plaquetas para la cicatrización
| 6/23/2022 |
4/27/2023 |
Pneumatic Compression Pumps
| 4/27/2023 |
11/1/2022 |
Preimplantation Genetic Testing
| 9/22/2022 |
2/2/2023 |
Prueba genética para el diagnóstico prenatal invasivo
| 2/2/2023 |
2/2/2023 |
Mastectomía profiláctica
| 2/2/2023 |
2/2/2023 |
Prostatectomía
| 2/2/2023 |
11/10/2022 |
Prótesis
| 10/27/2022 |
12/8/2022 |
Proton Beam, Neutron Beam and Carbon Ion Radiation Therapy
| 12/8/2022 |
10/27/2022 |
Pudendal Neuralgia Treatments
| 10/27/2022 |
10/27/2022 |
Rehabilitación pulmonar
| 10/27/2022 |
9/22/2022 |
Radiofrequency Tumor Ablation
| 9/22/2022 |
3/23/2023 |
Pérdida de embarazo recurrente
| 3/23/2023 |
7/27/2022 |
Cirugía de reducción de mamas
| 7/27/2022 |
1/1/2020 |
Rexulti (brexpiprazole)
| 5/25/2022 |
7/27/2022 |
Artritis reumatoide: marcadores biológicos y evaluación farmacológica
| 7/27/2022 |
5/25/2023 |
Rhinoplasty-Septoplasty

| 5/25/2023 |
9/22/2022 |
Scanning Computerized Ophthalmic Diagnostic Imaging
| 9/22/2022 |
3/1/2023 |
Pruebas serológicas y fecales para la detección de enfermedad intestinal inflamatoria (IBD)
| 6/23/2022 |
5/25/2023 |
Severe Acute Respiratory Syndrome Coronavirus 2 Serologic (Antibody) Testing
| 5/25/2023 |
5/12/2023 |
Severe Acute Respiratory Syndrome Coronavirus 2 Viral Testing

| 9/22/2022 |
8/25/2022 |
Artroplastia de hombro
| 8/25/2022 |
3/23/2023 |
Sustitutos de piel y tejido
| 2/2/2023 |
12/8/2022 |
Skin Lesion Surveillance Technologies
| 12/8/2022 |
12/8/2022 |
Skysona (elivaldogene autotemcel)
| 12/8/2022 |
2/2/2023 |
Sleep Studies, Adults
| 2/2/2023 |
4/27/2023 |
Solid Organ Transplants
| 4/27/2023 |
9/22/2022 |
Speech Generating Devices, Voice Prostheses
| 9/22/2022 |
12/8/2022 |
Terapia del habla
| 12/8/2022 |
1/1/2023 |
Estimuladores de la médula espinal
| 6/23/2022 |
1/1/2023 |
Cirugía de descompresión espinal
| 8/25/2022 |
12/8/2022 |
Cirugía de fusión espinal
| 12/8/2022 |
10/27/2022 |
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy
| 8/25/2022 |
3/23/2023 |
Support Garments, Fabric
| 3/23/2023 |
12/8/2022 |
Temporomandibular Joint Disorders
| 12/8/2022 |
1/1/2023 |
Thyroid Surgeries (Thyroidectomy and Lobectomy)
| 10/27/2022 |
5/26/2022 |
Tilt Table Testing
| 5/26/2022 |
4/27/2023 |
Tinnitus Treatments
| 4/27/2023 |
8/25/2022 |
Tissue Doppler Imaging (Tissue Doppler Echocardiography, Tissue Doppler
| 8/25/2022 |
3/23/2023 |
Transcatheter Intravascular Stents
| 3/23/2023 |
4/27/2023 |
Procedimientos de válvula transcatéter
| 4/27/2023 |
4/27/2023 |
Transcranial Magnetic Stimulation and Cranial Electrical Stimulation
| 3/23/2023 |
8/25/2022 |
Ultraviolet Light (Including Laser) Therapy for Skin Conditions
| 8/25/2022 |
4/1/2023 |
Urinary Bladder Dysfunction
| 12/8/2022 |
6/23/2022 |
Tratamientos quirúrgicos para fibromas uterinos
| 6/23/2022 |
1/1/2023 |
Vagus Nerve Stimulation
| 8/25/2022 |
3/23/2023 |
Varicose Vein Treatments
| 3/23/2023 |
3/23/2023 |
Ventricular Assist Device Total Artificial Heart
| 3/23/2023 |
9/22/2022 |
Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications
| 9/22/2022 |
7/27/2022 |
Prueba de vitamina D
| 7/27/2022 |
3/23/2023 |
Whole Genome/Exome Sequencing and Genome-Wide Association Studies
| 3/23/2023 |
3/1/2023 |
Whole Mitochondrial Genome Sequencing and Multigene Panels for Mitochondrial Disorders
| 3/1/2023 |
4/27/2023 |
Zynteglo (betibeglogene autotemcel)
| 12/8/2022 |