Medical and Administrative A-Z Index

Document Title Document Type Document Size Effective Date
A
Ablative Treatment for Malignant Breast Tumor - (0540) PDF 99kB 03/15/2021
Abortion - (A006) PDF 78kB 09/01/2021
Acupuncture - (CPG 024) PDF 268kB 04/15/2021
Adoptive Immunotherapy - (0225) PDF 237kB 11/15/2021
Adult and Pediatric Oncology Imaging Online Resource
Airway Clearance Devices in the Ambulatory Setting - (0069) PDF 173kB 10/15/2021
Allergy Testing and Non-Pharmacologic Treatment - (0070) PDF 322kB 04/15/2021
Ambulance Services - (0555) PDF 111kB 10/15/2021
Ambulatory Assistance Devices - (0050) PDF 107kB 03/15/2021
Ambulatory External and Implantable Electrocardiographic Monitoring - (0547) PDF 497kB 10/15/2021
American Society of Addiction Medicine (ASAM) Guideline Online Resource
Anesthesia and Facility Services for Dental Treatment - (0415) PDF 140kB 08/15/2021
Anesthesia Services for Interventional Pain Management Procedures in an Adult - (0551) PDF 264kB 02/15/2021
Angioplasty (Extracranial, Intracranial) and Intracranial Aneurysm Repair - (0545) PDF 223kB 11/15/2021
Atherosclerotic Cardiovascular Disease Risk Assessment: Emerging Laboratory Evaluations - (0137) PDF 431kB 08/15/2021
Athletic Pubalgia Surgery - (0522) PDF 108kB 07/15/2021
Attention-Deficit/Hyperactivity Disorder (ADHD): Assessment and Treatment - (0231) PDF 287kB 01/15/2021
Authorized Generics - (A008) PDF 71kB 10/01/2021
Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447) PDF 327kB 01/15/2021
Autologous Cell Therapy for Cardiac and Peripheral Arterial Disease - (0287) PDF 236kB 04/15/2021
Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP]) - (0507) PDF 319kB 10/15/2021
Autonomic Nerve Function Testing - (0506) PDF 130kB 02/15/2021
Axial/Spinal Decompression Therapy/Mechanical Traction (Provided in a Clinic Setting) - (CPG 275)

PDF 143kB 04/15/2021
B
Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation - (0480) PDF 242kB 04/15/2021
Bariatric Surgery and Procedures - (0051) PDF 867kB 10/15/2021
Behavioral Health Coaching and Peer Support Services - (A015) PDF 77kB 04/15/2021
Benign Prostatic Hyperplasia (BPH) Treatments - (0159) PDF 340kB 09/15/2021
Biofeedback - (CPG 294) PDF 556kB 11/15/2021
Biventricular Pacing/Cardiac Resynchronization Therapy (CRT) - (0174) PDF 361kB 12/15/2020
Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift - (0045) PDF 183kB 04/15/2021
Bone, Cartilage, and Ligament Graft Substitutes - (0118) PDF 308kB 02/15/2021
Bone Growth Stimulators: Electrical (Invasive, Noninvasive), Ultrasound - (0084) PDF 187kB 05/15/2021
Bone Mineral Density Measurement - (0300) PDF 190kB 04/15/2021
Brachytherapy Online Resource
Breast Implant Removal - (0048) PDF 144kB 01/15/2021
Breast Pumps - (0046) PDF 98kB 06/15/2021
Breast Reconstruction Following Mastectomy or Lumpectomy - (0178) PDF 364kB 04/15/2021
Breast Reduction - (0152) PDF 145kB 08/15/2021
Bronchial Thermoplasty - (0502)

PDF 232kB 07/15/2021
C
Capsule Endoscopy Online Resource 01/01/2020
Cardiac Electrophysiological (EP) Studies - (0532) PDF 209kB 10/15/2021
Cardiac Nuclear Imaging Online Resource
Cardiac Rehabilitation (Phase II Outpatient) - (0073) PDF 263kB 11/15/2021
Cardiac Stress Echocardiography Online Resource
Carotid Intima-Media Thickness Measurement - (0475) PDF 217kB 05/15/2021
Category III Current Procedural Terminology (CPT®) Codes - (0558) PDF 74kB 08/15/2021
Cervical Cancer Screening Visualization Technologies - (0127) PDF 157kB 09/15/2021
Cervical Fusion - (0527) PDF 181kB 06/15/2021
Chiropractic Care - (CPG 278) PDF 280kB 03/15/2021
Clinical Trials – (A003) PDF 85kB 02/17/2021
Cochlear and Auditory Brainstem Implants - (0190) PDF 381kB 11/15/2021
Cognitive Rehabilitation - (CPG 270) PDF 257kB 07/15/2021
Colorectal Cancer Screening and Surveillance - (0148) PDF 391kB 10/15/2021
Comparative Genomic Hybridization (CGH)/Chromosomal Microarray Analysis (CMA) for Selected Hereditary Conditions - (0493) PDF 219kB 11/15/2021
Complementary and Alternative Medicine - (0086) PDF 589kB 02/15/2021
Complex Lymphedema Therapy (Complete Decongestive Therapy) - (CPG 157) PDF 207kB 05/15/2021
Computed Tomography (CT) Online Resource
Computed Tomography Angiography (CTA) Online Resource
Computed Tomography Angiography (CTA) and Magnetic Resonance Angiography (MRA) Online Resource
Computed Tomography for Lung Cancer Screening Online Resource
Computerized Dynamic Posturography (CDP) - (0270) PDF 89kB 12/15/2020
Continuous Passive Motion (CPM) Devices - (0198) PDF 145kB 08/15/2021
Corneal Remodeling for Refractive Errors - (0141) PDF 335kB 11/15/2021
COVID-19: In Vitro Diagnostic Testing - (0557) PDF 261kB 10/15/2021
Custodial and Non-Skilled Services - (A012)

PDF 77kB 10/15/2021
D
Deep Brain, Motor Cortex and Responsive Cortical Stimulation - (0184) PDF 462kB 11/15/2021
Dermabrasion and Chemical Peels - (0505) PDF 132kB 06/15/2021
Diabetes Equipment and Supplies - (0106) PDF 544kB 07/01/2021
Diagnostic Cardiac Catheterization Online Resource
Diagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy - (0554) PDF 330kB 07/10/2021
Diaphragmatic/Phrenic Nerve Stimulation - (0391) PDF 306kB 07/15/2021
Discography - (0393) PDF 228kB 11/15/2021
Distraction Osteogenesis (DO) for Craniofacial Deformities - (0407) PDF 143kB 10/15/2021
Donor Lymphocyte Infusion and Hematopoietic Progenitor Cell (HPC) Boost - (0261) PDF 127kB 07/15/2021
Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery - (0481) PDF 187kB 04/15/2021
Drug Testing - (0513) PDF 152kB 11/15/2021
Duplex Scan to Evaluate for Carotid Artery Stenosis - (0542)

PDF 233kB 07/15/2021
E
Electrical Stimulation Therapy and Home Devices - (0160) PDF 749kB 09/15/2021
Electric Stimulation for Pain, Swelling and Function in a Clinic Setting - (CPG 272) PDF 311kB 08/15/2021
Electrodiagnostic Testing (EMG/NCV) - (CPG 129) PDF 257kB 10/15/2021
Electroencephalography - (0521) PDF 140kB 01/15/2021
Emergency Room Services - (A005) PDF 66kB 10/01/2021
Emerging Surgical Procedures for Glaucoma - (0035) PDF 408kB 09/15/2021
Endometrial Ablation - (0013) PDF 157kB 02/15/2021
Epidural Adhesiolysis - (CMM 207) Online resource
Epidural Steroid Injections - (CMM 200) Online resource
Esophagogastroduodenoscopy (EGD) Online Resource 01/01/2020
Exhaled Nitric Oxide in the Management of Respiratory Disorders - (0439) PDF 287kB 12/15/2020
External Counterpulsation - (0058) PDF 169kB 05/15/2021
Extracorporeal Photopheresis - (0320) PDF 117kB 05/15/2021
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds - (0004)

PDF 394kB 11/15/2021
F
Facet Joint Injections / Medial Branch Blocks - (CMM 201) Online resource
Fecal Bacteriotherapy - (0516) PDF 304kB 09/15/2021
Fetal Surgery - (0175) PDF 233kB 07/15/2021
Flow Cytometry - (0538) PDF 153kB 05/15/2021
Foot Care Services - (0277)

PDF 97kB 03/15/2021
G
Gait Analysis - (0315) PDF 106kB 04/15/2021
Gastric Pacing/Gastric Electrical Stimulation (GES) - (0103) PDF 212kB 11/15/2021
Gastrointestinal Endoscopic Procedure Esophagogastroduodenoscopy (EGD) Online Resource
Genetic Testing Collateral Document PDF 628kB 10/15/2021
Genetic Testing for Hereditary and Multifactorial Conditions - (0052) PDF 449kB 10/15/2021
Genetic Testing for Hereditary Cancer Susceptibility Syndromes - (0518) PDF 334kB 07/15/2021
Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias - (0517) PDF 245kB 11/15/2021
Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514) PDF 555kB 07/15/2021
Genetic Testing Recommendation Form

Online Resource
H
Headache and Occipital Neuralgia Treatment - (0063) PDF 193kB 06/15/2021
Head and Neck Ultrasound - (0549) PDF 252kB 07/15/2021
Hearing Aids - (0093) PDF 302kB 05/15/2021
Heart, Lung, and Heart-Lung Transplantation - (0129) PDF 284kB 09/15/2021
Helicobacter Pylori Serology Testing –(0308) PDF 89kB 05/15/2021
High Intensity Focused Ultrasound (HIFU) - (0274) PDF 297kB 01/15/2021
Hip Replacement/Arthroplasty - (CMM 313) Online Resource
Hip Surgery - Arthroscopic and Open Procedures - (CMM 314) Online resource
Home Traction Devices - Cervical and Lumbar - (CPG 265) PDF 185kB 04/15/2021
Home Ventilators - (0546) PDF 169kB 10/15/2021
Hospice Care - (0462) PDF 146kB 02/15/2021
Hospital Beds and Accessories - (0273) PDF 119kB 01/15/2021
Hospitalization for the Initiation of a Ketogenic Diet - (0359) PDF 94kB 06/15/2021
Hyperbaric and Topical Oxygen Therapies - (0053) PDF 335kB 09/15/2021
Hyperthermia

Online Resource
I
Image-Guided Radiation Therapy (IGRT) Online Resource
Implantable Cardioverter Defibrillator (ICD) - (0181) PDF 401kB 05/15/2021
Implantable Infusion Pump for Non-Musculoskeletal Conditions - (0370) PDF 141kB 12/15/2020
Implantable Intrathecal Drug Delivery Systems - (CMM 210) Online Resource
Infertility Services - (0089) PDF 441kB 10/15/2021
Inhaled Nitric Oxide (INO) - (0453) PDF 425kB 07/15/2021
Injectable Fillers - (0511) PDF 172kB 05/15/2021
Inpatient Acute Rehabilitation - (0427) PDF 164kB 02/15/2021
Inpatient Admission for Radiation Therapy - (0408) PDF 109kB 08/15/2021
Intensive Behavioral Interventions - (0499) PDF 202kB 01/15/2021
Interspinous Process Spacer Devices - (0448) PDF 205kB 04/15/2021
Intervertebral Disc (IVD) Prostheses - (0104) PDF 373kB 01/15/2021
Intestinal and Multivisceral Transplantation - (0288) PDF 128kB 12/15/2020
Intraocular Lens Implant - (0125) PDF 162kB 09/15/2021
Intraoperative Monitoring - (0509)

PDF 422kB 09/15/2021
K
Kidney Transplantation, Pancreas-Kidney Transplantation, and Pancreas Transplantation Alone - (0146) PDF 181kB 10/15/2021
Knee Replacement/Arthroplasty - (CMM 311) Online resource
Knee Surgery: Arthroscopic and Open Procedures - (CMM 312)

Online Resource
L
Laboratory Testing for Transplantation Rejection - (0465) PDF 222kB 12/15/2020
Laser Interstitial Thermal Therapy - (0528) PDF 207kB 10/15/2021
Liver and Liver-Kidney Transplantation - (0355) PDF 203kB 05/15/2021
Long Term Care Hospitals (LTCH)  - (A011) PDF 74kB 09/01/2021
Low-Level Laser and High-Power Laser Therapy - (CPG 030) PDF 232kB 03/15/2021
Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, including Sacroiliac Fusion - (0303) PDF 450kB 04/15/2021
Lyme Disease Treatment - Antibiotic Treatment - (0400)

PDF 343kB 08/15/2021
M
Magnetic Resonance Angiography (MRA) Online Resource
Magnetic Resonance Imaging (MRI) Online Resource
Magnetic Resonance Imaging (MRI), Cardiac Online Resource
Magnetic Resonance Imaging (MRI) of the Breast Online Resource
Magnetic Resonance Spectroscopy (MRS) Online Resource
Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403) PDF 309kB 08/15/2021
Malignant Melanoma Surveillance Technologies - (0240) PDF 227kB 10/15/2021
Mammary Ductoscopy, Aspiration and Lavage - (0057) PDF 192kB 01/15/2021
Manipulation Under Anesthesia (MUA) - (0276) PDF 137kB 10/15/2021
Metatarsophalangeal Joint Replacement - (0446) PDF 460kB 09/15/2021
Midwife, Home Birth and Non-Clinical Maternal Services - (A002) PDF 86kB 02/15/2021
Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) Procedures - (0019) PDF 502kB 08/15/2021
Minimally Invasive Spine Surgery Procedures and Trigger Point Injections - (0139) PDF 455kB 07/15/2021
Miscellaneous Musculoskeletal Procedures - (0515) PDF 241kB 03/15/2021
Molecular Diagnostic Testing for Hematology and Oncology Indications - (0520)

PDF 604kB 08/15/2021
N
Negative Pressure Wound Therapy/Vacuum-Assisted Closure (VAC) for Nonhealing Wounds - (0064) PDF 236kB 05/15/2021
Neuropsychological Testing - (0258) PDF 359kB 08/15/2021
Neutron Beam Radiation Therapy for Cancer Treatment Online Resource
Non-Participating Laboratory Services - (A001) PDF 61kB 01/15/2021
Nonpharmacological Treatments for Atrial Fibrillation - (0469) PDF 597kB 11/15/2021
Nucleic Acid Pathogen Testing - (0530) PDF 395kB 09/15/2021
Nutritional Support - (0136)

PDF 256kB 09/15/2021
O
Occupational Therapy - (CPG 155) PDF 281kB 07/15/2021
Omnibus Codes - (0504) PDF 1142kB 11/15/2021
Oncology Imaging Guidelines (Adult and Pediatric) Online Resource
Oral Cancer Screening Systems - (0372) PDF 183kB 12/15/2020
Orthognathic Surgery - (0209) PDF 119kB 10/15/2021
Orthotic Devices and Shoes - (0543) PDF 606kB 07/15/2021
Otoplasty and External Ear Reconstruction - (0335)

PDF 128kB 04/15/2021
P
Pacemaker Online Resource
Pancreatic Islet Cell Transplantation - (0107) PDF 155kB 06/15/2021
Panniculectomy and Abdominoplasty - (0027) PDF 99kB 03/15/2021
Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG 111) PDF 218kB 07/15/2021
Pediatric Intensive Feeding Programs - (0422) PDF 114kB 12/15/2020
Pelvic Denervation Procedures - (0368) PDF 117kB 06/15/2021
Pelvis Imaging Amendment to Cigna-eviCore General Pelvis Imaging Guideline - (DV001) ---- future effective policy PDF 79kB 02/01/2022
Percutaneous Revascularization of the Lower Extremities in Adults - (0537) PDF 264kB 03/15/2021
Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty - (0040) PDF 271kB 06/15/2021
Peripheral Nerve Destruction for Pain Conditions - (0525) PDF 434kB 03/15/2021
Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation - (0539) PDF 143kB 03/15/2021
Pharmacogenetic Testing for Non-Cancer Indications - (0500) PDF 205kB 02/15/2021
Phototherapy, Photochemotherapy, and Excimer Laser Therapy for Dermatologic Conditions - (0031) PDF 312kB 09/15/2021
Physical Performance Test or Measurement - (CPG 295) PDF 238kB 11/15/2021
Physical Therapy - (CPG 135) PDF 131kB 07/15/2021
Plantar Fasciitis Treatments - (0097) PDF 311kB 02/15/2021
Plasma Brain Natriuretic Peptide in the Outpatient Setting - (0028) PDF 263kB 11/15/2021
Plasmapheresis - (0153) PDF 252kB 06/15/2021
Pneumatic Compression Devices - (0354) PDF 216kB 06/15/2021
Positron Emission Tomography (PET) Online Resource
Preoperative Inpatient Admissions - (0402) PDF 84kB 08/15/2021
Pressure Reducing Surfaces - (0042) PDF 157kB 05/15/2021
Preventive Care Services - (A004) PDF 345kB 10/15/2021
Prolotherapy - (CMM 204) Online Resource
Prostate-Specific Antigen (PSA) Screening for Prostate Cancer - (0215) PDF 252kB 04/15/2021
Prosthetic Devices - (0536) PDF 296kB 01/15/2021
Proton Beam Therapy

Online Resource
R
Radiation Therapy for Cancers Online Resource
Radiofrequency Joint Ablations / Denervation - (CMM 208) Online Resource
Radioimmunotherapy with Zevalin Online Resource
Range of Motion Testing - (CPG 146) PDF 78kB 06/15/2021
Recurrent Pregnancy Loss: Diagnosis and Treatment - (0284) PDF 234kB 02/15/2021
Redundant Skin Surgery - (0470) PDF 103kB 06/15/2021
Regional Sympathetic Blocks - (CMM 209) Online Resource
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119) PDF 240kB 06/15/2021
Rosacea Procedures - (0482)

PDF 107kB 07/15/2021
S
Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation - (0404) PDF 402kB 10/15/2021
Sacroiliac Joint Procedures - (CMM 203) Online Resource
Scar Revision - (0328) PDF 196kB 05/15/2021
Scrotal Ultrasound - (0548) PDF 187kB 07/15/2021
Seat Lift Mechanism, Patient Lifts and Standing Devices - (0343) PDF 112kB 06/15/2021
Selective Internal Radiation Therapy (SIRT) Online Resource
Sensory and Auditory Integration Therapy - Facilitated Communication - (CPG 149) PDF 192kB 07/15/2021
Serological Testing for Inflammatory Bowel Disease - (0121) PDF 291kB 12/15/2020
Shoulder Arthroplasty / Replacement / Resurfacing / Revision / Arthrodesis - (CMM 318) Online resource
Shoulder Surgery - Arthroscopic and Open Procedures - (CMM 315) Online resource
Site of Care: High-tech Radiology - (0550) PDF 83kB 02/22/2021
Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures - (0553) PDF 168kB 04/02/2021
Sleep Management Online Resource
Speech Generating Devices - (0049) PDF 119kB 07/15/2021
Speech Therapy - (0177) PDF 253kB 12/15/2020
Spinal Cord and Dorsal Root Ganglion Stimulation - (CMM 211) Online Resource
Spinal Ultrasound - (CPG 038) PDF 121kB 09/15/2021
Staff-Assisted Home Hemodialysis - (0229) PDF 149kB 11/15/2021
Stem Cell Therapy for Orthopaedic Applications - (0552) PDF 189kB 03/15/2021
Stem Cell Transplantation: Blood Cancers - (0533) PDF 422kB 08/15/2021
Stem Cell Transplantation: Non-cancer Disorders - (0535) PDF 287kB 12/15/2020
Stem Cell Transplantation: Solid Tumors - (0534) PDF 182kB 01/15/2021
Strapping and Taping - (CPG 143) PDF 408kB 05/15/2021
Subtalar Arthroereisis - (0486) PDF 119kB 10/15/2021
Surgical Treatment for Chest Wall Deformities - (0309) PDF 149kB 04/15/2021
Surgical Treatment for Hyperhidrosis - (0037) PDF 127kB 01/15/2021
Surgical Treatment for Lymphedema and Lipedema - (0531) PDF 407kB 11/15/2021
Surgical Treatment of Gynecomastia - (0195) PDF 127kB 10/15/2021
Surgical Treatments for Obstructive Sleep Apnea - (0158)

PDF 340kB 10/15/2021
T
Temporomandibular Joint (TMJ) Disorder Surgery - (0156) PDF 122kB 12/15/2020
Tests for the Evaluation of Preterm Labor and Premature Rupture of Membranes - (0099) PDF 260kB 07/15/2021
Thermal Shrinkage - (0176) PDF 107kB 07/15/2021
Tilt Table Testing - (0066) PDF 121kB 03/15/2021
Tissue Engineered Skin Substitutes - (0068) PDF 1238kB 10/15/2021
Total Ankle Arthroplasty/Replacement - (0285) PDF 149kB 02/15/2021
Transcatheter Ablation for the Treatment of Supraventricular Tachycardia in Adults - (0529) PDF 198kB 04/15/2021
Transcatheter Closure of Cardiovascular Defects - (0011) PDF 347kB 11/15/2021
Transcatheter Heart Valve Procedures - (0501) PDF 556kB 12/15/2020
Transcranial Magnetic Stimulation - (0383) PDF 457kB 03/15/2021
Transplantation Donor Charges - (0132) PDF 169kB 11/15/2021
Transthoracic Echocardiography in Adults - (0510) PDF 439kB 11/15/2021
Transthoracic Echocardiography in Children - (0523) PDF 424kB 11/15/2021
Transvaginal Ultrasound, Non-Obstetrical - (0398) PDF 216kB 01/15/2021
Treatment of Cutaneous and/or Deep Tissue Hemangioma, Port Wine Stain and Other Vascular Lesions - (0313) PDF 193kB 05/15/2021
Treatment of Gender Dysphoria - (0266) PDF 192kB 05/18/2021
Tumor In Vitro Chemosensitivity and Chemoresistance Assays - (0203)

PDF 193kB 05/15/2021
U
Ultrasound-guided Radiofrequency Ablation for Uterine Fibroids - (0602) PDF 114kB 05/19/2021
Ultrasound in Pregnancy (including 3D, 4D and 5D Ultrasound) - (0142) PDF 153kB 06/15/2021
Umbilical Cord Blood Banking - (0466)

PDF 102kB 06/15/2021
V
Vagus Nerve Stimulation (VNS) - (0350) PDF 292kB 12/15/2020
Varicose Vein Treatments - (0234) PDF 484kB 11/15/2021
Venous Angioplasty and/or Stent Placement in Adults - (0541) PDF 288kB 07/15/2021
Ventricular Assist Devices (VADs), Percutaneous Cardiac Support Systems and Total Artificial Heart - (0054) PDF 455kB 12/15/2020
Vitamin D Testing - (0526)

PDF 293kB 03/15/2021
W
Wearable Cardioverter Defibrillator and Automatic External Defibrillator - (0431) PDF 252kB 05/15/2021
Wheelchairs/Power Operated Vehicles - (0030) PDF 357kB 05/15/2021
Whole Body Dual X-Ray Absorptiometry (DXA) - (0325) PDF 104kB 03/15/2021
Whole Exome and Whole Genome Sequencing - (0519) PDF 189kB 04/15/2021
Whole Exome Sequencing Recommendation Form

PDF 04/03/2017