Coverage Policy – Arkansas Blue Cross and Blue Shield

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Autologous or Allogeneic Stem &/or Progenitor Cell Support- POEMS Abatacept (Orencia) for Rheumatoid Arthritis Ablation Ther Atrial Fibrillation (Pulmo Venous Isolation, Radiofreq, Cryo, Ablation Therapy for Atrial Arrhythmias other than Atrial Fibrillation Ablation Therapy, Radiofrequency and Cryoablation of Pulmonary Tumors Acupuncture Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Tx of HER-2+ Malignancies Adoptive Immunotherapy Alcohol Injections for Treatment of Peripheral Neuromas Alemtuzumab ( Lemtrada) Allergen Specific IgE In Vitro Testing Allergy Immunotherapy Allergy Testing, Metal Allergy Testing, Serial Endpoint Testing Allogeneic Donor Leukocyte Infusion Ambulatory Blood Pressure Monitoring Amevive (Alefacept) Amniocentesis/Chorionic Villus Samp-Detect Fetal Hereditary/Chromosomal Abn Amniotic Membrane and Amniotic Fluid Injections Angioplasty/Stent, Percutaneous, Carotid Artery Angioplasty/Stenting/Atherectomy of LE, Abd Aortic, & Visceral Arteries Annuloplasty: Percutaneous Intradiscal: IDET, PIRFT or Biacuplasty Anti-PD-1 (programmed death receptor-1)Therapy (Pembrolizumab)(Nivolumab) Antigen Leukocyte Antibody Test (ALCAT) Antineoplaston Cancer Therapy Antiprothrombin Antibody Antithrombin III Replacement Apheresis, Therapeutic (Plasma Exchange Transfusion) Aqueous Shunts and Devices for Glaucoma Arthroereisis for Pes Planus (Flat Feet) (Subtalar stabilization) Artificial Heart, Total Artificial Vertebral Disc, Cervical Spine Artificial Vertebral Disc, Lumbar Spine Atezolizumab (Tecentriq) Auditory Evoked Potential Autism Spectrum Disorder, Early Behavioral Intervention Autism Spectrum Disorder, Interventions NOT Early Behavioral Intervention Autologous Chondrocyte Implant for Focal Articular Cartilage Lesions Autologous Stem-cell Therapy to Treat Peripheral Arterial Disease Automated Whole Breast Ultrasound Balloon Sinuplasty Biochemical Marker's, Alzheimer's Disease Biofeedback as a Trtmnt of Chronic Pain Biofeedback as a Trtmnt of Fecal Incontinence or Constipation Biofeedback as a Trtmnt of Headache Biofeedback as a Trtmnt of Urinary Incontinence in Adults Biofeedback for Miscellaneous Indications Bioimpedance Devices for Detection of Lymphedema Biomarker Panel Testing for Systemic Lupus Erythematosus Biomarker Test (Vectra DA) Monitoring Disease Activity-Rheumatoid Arthriti Biomarker Test, reDx, Diabetes Risk Score Biomarker, Methotrexate Polyglutamates Predict Response Methotrexate -RA Biomarker, Serum Human Epididymis Protein 4 (HE4) Biomarkers for Liver Disease Biventricular Pacemakers for the Trtmnt of Congestive Heart Failure Blepharoplasty/Blepharoptosis Blinatumomab (Blincyto) Blood/Platelet-Derived Growth Factors for Wound Healing Bone Growth Stim, Elec, Adjunct to Spinal Fusion Bone Growth Stim, Elect, Appendicular Skeleton Bone Markers (Collagen Crosslinks as Biological Markers of Bone Turnover) Bone Mineral Density Study Bone Morphogenetic Protein Boron Neutron Capture Therapy Brachytherapy, Brain Tumors Brachytherapy, Breast Brachytherapy, Endobronchial Brachytherapy, Prostate, High-Dose Rate Temporary Brachytherapy, Prostate, Low-dose Rate Brachytherapy, Radioembolization Primary & Metastatic Tumors of the Liver Bronchial Thermoplasty Capsaicin (Qutenza) for the Trtmnt of Post-Herpetic Neuralgia Cardiac Event Recorder, External Loop or Continuous Recorder Cardiac Event Recorder, Insertable Loop Recorder Cardiac Event Recorder, Mobile Telemetry Cardiac Rehabilitation Cardiovascular Risk Panels Cardioverter Defibrillator; Implantable, SubQ, & Wearable Carotid Intima -Media Thickness, US Meas Assess Subclinic Atherosclerosis Certified Nurse Midwives Certified Nurse Practitioners Chelation Therapy Chemical Ecology (Environ Illness, Multi Chem Sensitiv, Environ Hypersensi Chemical Labyrinthectomy in the Trtmnt of Meniere's Syndrome Chemical Peels Chemodenerv BOTOX Chemodenerv BOTOX for the Trtmnt of Chronic Migraine Headache Chemosensitivity and Chemoresistance Assays, In-Vitro Chemotherapy for Malignancy Chromoendoscopy as an Adjunct to Colonoscopy Chronic Cerebrospinal Venous Insufficiency in MS, Diagnosis & Trtmnt Chronic Intermittent Intravenous Insulin Therapy (CIIIT) Circulating Tumor Cells in the Mgmt of Patients with Cancer, Detection of Clinical Nurse Specialist Closure Devices-Atrial/Ventricular Septal Defects (ASD, VSD) or PFO, Percut Cochlear Implant Cognitive Rehabilitation Cold Therapy Computed Tomography (CT) Cardiac and Coronary Artery Computed Tomography (CT) Perfusion Imaging Computed Tomography (CT) Scanning for Lung Cancer Screening Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedur Confocal Laser Endomicroscopy Continuous Passive Motion Device In the Home Setting Cord Blood as a Source of Stem Cells for Potential Disease Cord Blood as a Source of Stem Cells for Trtmnt of Identified Disease Corneal Collagen Cross-linking Corneal Topography Coronary Artery Calcium Scoring, Screening, to Predict Risk for Coronary Ar Corticosteroid Infusion of Middle Ear for Sudden Hearing Loss Cryosurgical Ablation of Breast Tumors, Benign and Malignant Cryosurgical Ablation of Pancreatic Cancer Cryosurgical Ablation of Primary or Metastatic Liver Tumors Cryosurgical Ablation of Prostate Cancer Cryosurgical Ablation of Renal Tumors Current Perception Threshold Test Cutting Guides and Custom Knee Implants Cytoreduction Surgery with Hyperthermic Intraperitoneal Chemotherapy Daclatasvir (Daklinza) Daratumumab (Darzalex) Digital Breast Tomosynthesis Digital Imaging Systems for the Detection of Diabetic Retinopathy Digital Motion X-ray (Cineradiography/Videoradiography) MusculoskeletalCond Digitization: Computer Enhanced X Ray Analysis for Spinal Evaluation Dopamine Transporter Imaging with Single Photon Emission CT (DAT-SPECT) Droxidopa (Northera) Dry Needling of Myofascial Trigger Points Eculizumab (Soliris) EKG, Signal Averaged Elec Stim, Auricular Stimulation and Cranial Electrotherapy Stimulation Elec Stim, Baroreflex Stim for the Trtmnt of Hypertension Elec Stim, Deep Brain (e.g. Parkinson, Dystonia, MS, Post Traumatic Dyskine Elec Stim, Occipital Nerve Stim for Trtmnt of Headaches Elec Stim, Percutaneous Electrical Nerve Stim(PENS) or PNT Elec Stim, Percutaneous Tibial Nerve Stim for the Trtmt Voiding Dysfunction Elec Stim, Transcutaneous Elec Nerve Stim Elec Stim, Vagus Nerve Stim for the Trtmnt of Depression Elec Stim, Vagus Nerve Stim for the Trtmnt of Essential Tremors Elec Stim, Vagus Nerve Stim for the Trtmnt of Fibromyalgia Elec Stim, Vagus Nerve Stim for the Trtmnt of Headaches Elec Stim, Vagus Nerve Stim for the Trtmnt of Heart Failure Elec Stim, Vagus Nerve Stim for the Trtmnt of Obesity Elec Stim, Vagus Nerve Stim for the Trtmnt of Seizures Elec/Electromagnetic Stim for the Trtmnt of Arthritis Electric Breast Pump (Hospital Grade) Electrical/Magnetic Stim, Pelvic Floor Muscles-Urinary & Fecal Incontinence Electrocardiogram, Computerized 2-Lead Analysis for the Diagnosis of CAD Electrocardiographic Body Surface Mapping Electromagnetic Navigation Bronchoscopy Electrophrenic Pacemaker (Diaphragmatic Pacemaker) ElectroStim and Electromagnetic Therapy for the Trtmnt of Wounds Endobronchial Valves Endothelial Function Testing, Noninvasive Endothelial Keratoplasty Endovascular Procedures, Intracranial Arterial Dz & Extracranial Vertebral Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections Epidural Adhesiolysis, Percutaneous Epiduroscopy Epiretinal Rad Ther for Age-Related Macular Degeneration ESWL for Plantar Fasciitis and Other Musculoskeletal Conditions ESWL in the Trtmnt of Peyronie's Disease Etanercept (Enbrel) External Enhanced Cardiac Counterpulsation (EECP) Extracorporeal Membrane Oxygenation for Adult Conditions Extracranial-Intracranial Bypass Surgery in Cerebrovascular Disease Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Fecal Microbiota Transplantation for the Treatment of Clostridium Difficile Femoroacetabular Impingement, Surgical Trtmnt of Fetal Fibronectin Enzyme Immunoassay Focal Treatments for Prostate Cancer Food and Chemical Sensitivity Testing Functional Anesthetic Discography Functional Intracellular Analysis Gait Analysis Galectin Measurement Gastric NeuroStim for Morbid Obesity Gastric NeuroStim for Trtmnt of Gastric and/or Small Bowel Paresi Gastroesophageal Reflux Disease (GERD), Magnetic Esophageal Ring Genetic Test: Analysis of MGMT Promoter Methylation in Malignant Gliomas Genetic Test: Aspirin Trtmnt, Lipoprotein(a) Variant(s) as a Decision Aid Genetic Test: Breast Ca Predict; Risk of Recurrence Need for Adjuvant Chem Genetic Test: Molecular Markers in Fine Needle Aspirates of the Thyroid Genetic Test: X-Linked Opitz G/BBB Syndrome, MID1 Mutation Testing Genetic Test: Acute Myeloid Leukemia, (FLT3 and NPM1) Genetic Test: Adolescent Idiopathic Scoliosis; Prediction of Disease Prog Genetic Test: Aid in the Mgmt of Psychiatric Meds & Conditions Genetic Test: Allopurinol Sensitivity (HLA-B*5801) Genetic Test: Alpha Thalessemia Genetic Test: Alpha-1 Antitrypsin Deficiency Genetic Test: Alzheimer's Disease Genetic Test: Amyotrophic Lateral Sclerosis Genetic Test: Asthma, HLA-DR and HLA-DQ Genotyping Genetic Test: Azothiaprine 6MP Sensitivity,Genotyping Phenotyping (TPMT) Genetic Test: BRCA1 or BRCA2 Mutations Genetic Test: Breast Ca Predict; Risk of Distant Metastasis Adjuvant Chem Genetic Test: Breast Ca Predict; Risk of Distant Metastasis Need Adjuvant C Genetic Test: Breast Ca; Risk Recurrence Need Adjuvamt Chemo (Oncotype Dx) Genetic Test: Canavan Disease Genetic Test: Cancer Susceptibility Panels Using Next Generation Sequencing Genetic Test: Carbamazepine HLA-B*1502 Genetic Test: Cardiac Ion Channelopathies Genetic Test: Celiac Disease, HLA Typing (HLA-DQ) Genetic Test: Cerebral Autosomal Dominant Arteriopathy (CADASIL) (NOTCH3) Genetic Test: CHARGE Syndrome Genetic Test: Chromosomal Microarray (CMA) & NGS Eval Pat Devel Delay/Autis Genetic Test: CMA Testing for the Evaluation of Pregnancy Loss Genetic Test: CML and ALL (BCR-ABL) Genetic Test: Colon Ca, KRAS, NRAS,BRAF Mutation-Tumor Sensitivity to Chemo Genetic Test: Colon Cancer, Gene Expression Profiling Genetic Test: Coronary Artery Disease, Testing to Predict Risk (Corus CAD) Genetic Test: Diagnosis & CA Risk Assessment for Prostate Cancer Genetic Test: Dilated Cardiomyopathy Genetic Test: Duchenne and Becker Muscular Dystrophy Genetic Test: Epilepsy Genetic Test: Facioscapulohumeral Muscular Dystrophy Genetic Test: Factor V Leiden Genetic Test: Fanconi Anemia Genetic Test: Fecal DNA to Detect Colorectal Cancer, Screening Genetic Test: Fetal RHD Genotyping Using Maternal Plasma Genetic Test: FMR 1 Mutations Including Fragile X Syndrome Genetic Test: Genotyping for 9p21 Single Nucleotide Polymorphisms-Cardio Genetic Test: Germline Mutations RET Protooncogene in Medullary Cx Thyroid Genetic Test: Head & Neck Cancer, EGFR Mutation Analysis Genetic Test: Heart Transplantation Rejection, AlloMap Testing Genetic Test: Hemochromatosis Genetic Test: HER2 Testing Genetic Test: Hereditary Pancreatitis Genetic Test: HERmark, HER2 Breast Cancer Assay Meas HER2 Tot Protein Ex Genetic Test: HLA-B*5701 Testing for Abacavir Hypersensitivity Reaction Genetic Test: Hypertrophic Cardiomyopathy, Predisposition Genetic Test: Inherited Peripheral Neuropathies (Charcot Marie Tooth, HNPP) Genetic Test: JAK2 and MPL Mutation Test for Myeloproliferative Disorders Genetic Test: KIF6 Predict Risk for CVD and/or Effectiveness of Statin Tx Genetic Test: KIT (c-KIT, CD117) Genetic Test: Lactase Insufficiency (-13910 C>T) Genetic Test: Li-Fraumeni Syndrome Genetic Test: Lynch Syndrome and Inherited Intestinal Polyposis Syndromes Genetic Test: Macular Degeneration Genetic Test: Melanoma, Hereditary Genetic Test: Melanoma, V600E Mutation Testing - Vemurafenib (Zelboraf) Genetic Test: Microarray-based Gene Exp Profile Analysis Prostate CA Mang Genetic Test: Microarray-Based Gene Expression Testing, CUP Genetic Test: Miscellaneous Genetic and Molecular Diagnostic Tests Genetic Test: Mitochondrial Disorders Genetic Test: Molecular Testing of Tumors for Genomic Profiling Genetic Test: Multiple Myeloma, Gene Expression Profiling Genetic Test: Mutation Testing for Limb-Girdle Muscular Dystrophies Genetic Test: Neurofibromatosis Genetic Test: PALB2 Mutations Genetic Test: PathFinderTG Molecular Testing Genetic Test: Pharmacogenetic Testing for Pain Management Genetic Test: Prenatal Analysis of Fetal DNA Detect Fetal Aneuploidy Genetic Test: Prothrombin Thrombophilia (G20210A) and MTHFR Mutations Genetic Test: PTEN Hamartoma Tumor Syndrome Genetic Test: Rett Syndrome Genetic Test: Statin-Induced Myopathy (SLCO1B1) Genetic Test: Tamoxifen Trtmnt (CYP2D6) Genetic Test: Testing for Use of 5-FU in Patients with Cancer Genetic Test: UGT1A1 to Predict Toxicity to Irinotecan Genetic Test: Universal Gene Test (Counsyl) Genetic Test: Use of Common Genetic Variants (SNPS), Nonfamilial Breast CA Genetic Test: Uveal Melanoma, Gene Expr Profile Predict Risk of Metastasis Genetic Test: Warfarin Dose/Response Genetic Test: Whole Exome Sequencing Genetic Testing: CHEK2 Mutations for Breast Cancer Glaucoma Evaluation, Ophthalmologic Techniques Glucose Monitoring, Continuous Golimumab (Simponi) Growth Hormone, Human Handheld Radio Spectroscopy for Intraoperative Assessment of Surg Margins.. HDC & Allo-Acute Lymphocytic Leukemia HDC & Allo-Acute Myelogenous Leukemia HDC & Allo-Auto-Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma HDC & Allo-Auto-Chronic Malignant Astrocytomas & Gliomas HDC & Allo-Chronic Myelogenous Leukemia HDC & Allo-Ewing's Sarcoma HDC & Allo-Genetic Diseases & Acquired Anamias HDC & Allo-Hematophagocytic lymphohistiocytosis HDC & Allo-Hodgkin's Disease HDC & Allo-Myelodysplastic Disease HDC & Allo-Non-Hodgkin's Lymphoma HDC & Allo-Primitive Neuroectodermal Tumors (PNET) & Ependymoma HDC & Allo-Solid Tumors of Childhood HDC & Auto-Acute Lymphocytic Leukemia HDC & Auto-Acute Myelogenous Leukemia HDC & Auto-Chronic Myelogenous Leukemia HDC & Auto-Ewing's Sarcoma HDC & Auto-followed by Nonmyeloablative Allogeneic SCT for Multiple Myeloma HDC & Auto-Germ Cell Tumors HDC & Auto-Hodgkin's Disease HDC & Auto-Multiple Myeloma HDC & Auto-Myelodysplastic Syndrome HDC & Auto-Non Hodgkin's Lymphomas HDC & Auto-Primitive Neuroectodermal Tumors (PNET) & Ependymoma HDC & Auto-Solid Tumors of Childhood HDC & Auto-Waldenstrom's Macroglobulinemia HDC & Autologous or Allogeneic Stem Cell Sup-Epith Ovarian Cancer HDC & Hematopoietic Stem Cell Support for Breast Cancer HDC & Hematopoietic Stem Cell Support-Autoim Diseases Include Mult HDC & Hematopoietic Stem Cell Support-Misc Solid Tumors Adults HDC -AL Amyloidosis (Light Chain Amyloidosis) Heartsbreath Test for Heart Transplant Rejection Detection Hemodynamic Monitoring of Heart Failure, Mgmt in the Outpatient Setting Hepatic Tumors, Ablative Procedures(PEI, Acetic Acid Inj, ILP, LITT) Hereditary Angioedema, Prophylaxis and Acute Treatment Hip Resurfacing Hippotherapy HIV Tropism, Testing Home Apnea Monitors Home Uterine Activity Monitor Homocysteine Measurement Hormone Pellet Implantation for Hormone Replacement Therapy Human Papilloma Virus Testing of Cervical Pap Smears Hyperbaric Oxygen Pressurization (HBO) Hyperhidrosis Trtmnt Hysteroscopic Placement Micro-Inserts in Fallopian Tubes Form Immune Cell Function Assay Immune Globulin, Intravenous and Subcutaneous Implantable Bone Conduction Hearing Aids Implantable Infusion Pump Implantable Telescope for the Trtmnt of Age-Related Macular Degeneration IMRT IMRT, Anus, Anal Canal IMRT, Breast IMRT, Lung IMRT, Prostate Infertility Services Infliximab (Remicade) Ingestible pH and Pressure Capsule Injection, Clostridial Collagenase Fibroproliferative Disorders Insulin Infusion Pumps, External Interferon Gamma-1B Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Interventions for Progressive Scoliosis Intradialytic Parenteral Nutrition Intraepidermal Nerve Fiber Density Intraoperative Neurophysiologic Monitoring Intraoperative Radiation Therapy Intrastromal Corneal Ring Segments, Implantation Intrauterine Systems, Progesterone or Progestogen-Releasing Intravenous Lidocaine or Ketamine Outpatient Management of Chronic Pain Intravitreal Implant, Dexamethasone (Ozurdex) Intravitreal Implant, Fluocinolone Acetonide (Retisert, Iluvien) Ipilimumab (Yervoy) Iron Therapy, Parenteral Irreversible Electroporation, Nanoknife Keratomileusis Keratophakia Keratoplasties, Refractive Keratoprosthesis Kyphoplasty, Percutaneous and Mechanical Vertebral Augmentation Lab Test: Identification of Microorganisms Using Nucleic Acid Probes Laser Treatment of Onychomycosis Laser Trtmnt of Congenital Port Wine Stain Hemangiomas Left Atrial Appendage, Closure Device, Percutaneous Leuprolide (Lupron) LITT for Brain Tumors Low Level Laser Therapy (LLLT) Lung Volume Reduction Surgery (LVRS) Lyme Disease, Intravenous Antibiotic Therapy and Associated Diagnostic Test Lymphedema Pumps (Pneumatic Compression Devices) Trtmnt of Lymphedema Macular Translocation Magnetic Resonance Spectroscopy Magnetoencephalography/Magnetic Source Imaging Mammoplasty, Reduction Mastectomy, Male Gynecomastia Mastectomy, Prophylactic Maze Procedure Measurement of Serum Antibodies to Infliximab and Adalimumab Measuremt of Exhaled Nitric Oxide Dx and Mgmt of Asthma & Other Resp Disord Measuremt of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) -Cardiovasul Measuremt of Serum Intermediate Density Lipoproteins (Remnant-like Partic Meniscal Allograft Transplantation and Synthetic Meniscal Implants Mepolizumab (Nucala) Metabolite Testing, Monitor Antimetabolite Therapy for IBS, CVD, ALL Microprocessor-Controlled Prostheses for the Lower Limb Microwave Ablation of Tumors Microwave Thermotherapy for Breast Cancer Minimally Invasive Image-Guided Lumbar Decompression for Spinal Stenosis Minimally Invasive Lumbar Interbody Fusion Mohs' Micrographic Surgery MR Guided Ultrasound Ablation - Uterine Fibroids and Other Tumors MRI Targeted Biopsy of the Prostate MRI, Breast MRI, Cardiac Applications MRI, Functional Multiple Sleep Latency/Maintenance of Wakefulness Test Multispectral Digital Skin Lesion Analysis (MelaFind) (MSDSLA) Multitarget PCR Testing for Dx of Bacterial Vaginosis (SureSwab) (NuSwab) Mutation Molecular Analysis for Targeted Therapy in Patients With NSCLC Myocardial Damage, Auto Cell Therapy(progenitor, hematopoietic SC, Myoblast Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure Myoelectric Prosthesis for the Upper Limb Natalizumab (Tysabri) Navigated Transcranial Magnetic Stimulation Needle Arthroscopy Nerve Conduction Studies (NCS), EMG and SEMG Nerve Graft For Patients Undergoing Radical Non-Nerve-Sparing Prostatectomy Nesiritide (Natrecor) for Use in the Outpatient Setting Neural Therapy Neurofeedback Neuromuscular Stim, Functional Non-Myeloablative Allo SCT Noninvasive Imaging Technologies to Detect Liver Fibrosis or Cirrhosis Novel Lipid Risk Factors in Risk Assessment & Management of CV Disease Nutritional Panel Testing (NutrEval, ONE FMV) Nutritional Supplements OATS and/or Mosaicplasty For Osteochondral Defects of the Knee Ocriplasmin (Jetrea) for Symptomatic Vitreomacular Adhesion Omalizumab (Xolair) Oophorectomy, Prophylactic Oprelvekin (Neumega) Optical Coherence Tomography Anterior Eye Segment Imaging Optical Coherence Tomography Imaging of Coronary Arteries Optical Diagnostic Devices, Evaluating Skin Lesions Suspected of Malignancy Orthopedic Applications of Stem Cell Therapy Orthoptic Training for the Trtmnt of Vision and Learning Disabilities Oscillatory Devices for Chest Physical Therapy Osteochondral Allograft and/or Mosaicplasty for Osteochondral Defects Knee Ovarian & Internal Iliac Vein Embolization Trtmnt of Pelvic Congest Syndrom Pain Management, Facet Joint Block Pain Management, Facet Nerve Denervation, other than Radiofreq Pain Management, Radiofreq Facet Joint Denervation Paliperidone Palmitate (Injectables Invega Sustenna & Invega Trinza) pasireotide Patient-actuated End Range Motion Stretching Devices PCSK9 INHIBITORS (Evolocumab) (Alirocumab) PDE-5 Inhibitors for Benign Prostatic Hypertrophy (Tadalafil) Percutaneous Transluminal Endovascular Graft for Abdominal Aortic Aneurysm Peripheral Subcutaneous Field Stimulation Periureteral Bulking Agents Trtmnt of Vesicoureteral Reflux (VUR) Periurethral Bulking Agents Trtmnt of urinary and Fecal Incontinence Peroral Endoscopic Myotomy (POEM) for Treatment of Esophageal Achalasia Pertuzumab PET or PET/CT for Anal Carcinoma PET or PET/CT for Brain Imaging, Non-malignant Dis PET or PET/CT for Breast Cancer PET or PET/CT for Carcinoma of Unknown Primary (CUP) PET or PET/CT for Cervical Cancer PET or PET/CT for Colorectal Cancer PET or PET/CT for Esophageal or Esophagogastric Junction (EGJ) Cancer PET or PET/CT for Gastric Cancer PET or PET/CT for Head and Neck Malignant Disease PET or PET/CT for Hodgkin's Lymphoma PET or PET/CT for Lymphadenopathy of Unknown Cause PET or PET/CT for Malignant Brain Tumors PET or PET/CT for Melanoma PET or PET/CT for Mesothelioma PET or PET/CT for Neuroendocrine Tumors PET or PET/CT for Non-Hodgkin's Lymphoma PET or PET/CT for Non-Small Cell Lung Cancer PET or PET/CT for Ovarian Cancer PET or PET/CT for Pancreatic Cancer PET or PET/CT for Pulmonary Langerhans Cell Histiocytosis PET or PET/CT for Renal Cell Carcinoma PET or PET/CT for Small Cell Lung Cancer PET or PET/CT for Soft Tissue Sarcoma, including GIST PET or PET/CT for Testicular Germ Cell Cancer PET or PET/CT for Thymoma/Thymic Carcinoma PET or PET/CT for Thyroid Cancer PET or PET/CT for Vulvar Carcinoma PET or PET/CT, Choline C 11 or FDG, for Prostate Cancer PET Scan for Alzheimer's-Beta Amyloid Imaging PET Scan for Alzheimer's-FDG PET Scan for Cardiac Applications PET Scan for Multiple Myeloma, Plasmacytoma Photochemotherapy (PUVA) Photochemotherapy, Extracorporeal Trtmnt of Cutaneous T-Cell Lymphoma Photochemotherapy, Extracorporeal Trtmnt of Graft-versus-Host Disease Photochemotherapy, Extracorporeal Trtmnt to Prevent Reject after Transplant Photodynamic Therapy for Dermatologic Conditions Photodynamic Therapy for Malignancy Photodynamic Therapy for Ophthalmology Phototherapy for Psoriasis Phototherapy for Vitiligo Physician Assistants Platelet-Rich Plasma (Autologous Growth Factors), Orthopedic Applications Plugs for Anal Fistula Repair Pneumatic Compression Device, Intermittent, after Hip and Knee Arthroplasty Polysomnography for Non-Respiratory Sleep Disorders Positional Magnetic Resonance Imaging Positional Plagiocephaly & Craniosynostoses: Adjustable Cranial Orthoses Positron Emission Mammography (PEM) Posturography, Dynamic/Static Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities PPACA FOR NGP: ABDOMINAL AORTIC ANEURYSM SCREENING PPACA FOR NGP: ALCOHOL MISUSE COUNSELING AND/OR SCREENING PPACA FOR NGP: ANEMIA, SCREENING, INFANTS, CHILDREN & ADOLESCENTS PPACA FOR NGP: ASPIRIN TO PREVENT CARDIOVASCULAR DISEASE IN ADULTS PPACA FOR NGP: ASPIRIN, TO PREVENT MORBIDITY & MORTALITY FROM PREECLAMPSIA PPACA FOR NGP: AUTISM SCREENING PPACA FOR NGP: BACTERIURIA SCREENING IN PREGNANT WOMEN PPACA FOR NGP: BICYCLE HELMET USE, CHILDREN & ADOLESCENTS PPACA FOR NGP: BLOOD PRESSURE, SCREENING, INFANTS, CHILDREN & ADOLESCENTS PPACA FOR NGP: BRCA TESTING; GENETIC COUNSELING AND EVALUATION PPACA FOR NGP: BREAST CANCER PREVENTIVE MEDICATION PPACA FOR NGP: BREAST CANCER SCREENING (MAMMOGRAPHY) PPACA FOR NGP: BREASTFEEDING COUNSELING PPACA FOR NGP: CARDIOMETABOLIC RISKS OF OBESITY, CHILDREN & ADOLESCENTS PPACA FOR NGP: CERVICAL CANCER SCREENING PPACA FOR NGP: CHLAMYDIAL INFECTION SCREENING IN WOMEN & ADOLESCENTS PPACA FOR NGP: COLORECTAL CANCER SCREENING PPACA FOR NGP: CONTRACEPTIVE USE AND COUNSELING PPACA FOR NGP: DENTAL CARIES PREVENTION IN PRESCHOOL CHILDREN PPACA FOR NGP: DEPRESSION SCREENING IN ADOLESCENTS PPACA FOR NGP: DEPRESSION SCREENING, ADULTS PPACA FOR NGP: DEVELOPMENTAL SCREENING PPACA FOR NGP: FOLIC ACID FOR PREVENTION OF NEURAL TUBE DEFECTS PPACA FOR NGP: GESTATIONAL DIABETES SCREENING PPACA FOR NGP: GONORRHEA PROPHYLAXIS, NEWBORN OPHTHALMIC PPACA FOR NGP: GONORRHEA SCREENING, WOMEN & ADOLESCENTS PPACA FOR NGP: HCV SCREENING PPACA FOR NGP: HEARING LOSS SCREENING IN NEWBORNS UP TO AGE 21 PPACA FOR NGP: HEP B VIRUS INFECTION, SCREENING, PREGNANCY, ADOL & ADULTS PPACA FOR NGP: HIGH BLOOD PRESSURE SCREENING IN ADULTS PPACA FOR NGP: HPV SCREENING FOR SEXUALLY ACTIVE WOMEN PPACA FOR NGP: HUMAN IMMUNODEFICIENCY VIRUS (HIV) COUNSELING & SCREENING PPACA FOR NGP: HYPOTHYROIDISM SCREENING IN NEWBORNS PPACA FOR NGP: IBC, TO PROMOTE HEALTHY DIET & EXERCISE, ADULTS PPACA FOR NGP: INTIMATE PARTNER VIOLENCE; SCREENING IN WOMEN PPACA FOR NGP: IRON DEFICIENCY ANEMIA SCREENING IN PREGNANT WOMEN PPACA FOR NGP: IRON SUPPLEMENTATION FOR CHILDREN PPACA FOR NGP: LEAD SCREENING, INFANTS & CHILDREN PPACA FOR NGP: LUNG CANCER SCREENING PPACA FOR NGP: MEDIA USE, SCREENING & COUNSELING PPACA FOR NGP: METABOLIC/HEMOGLOBIN SCREENING, NEWBORNS PPACA FOR NGP: OBESITY IN CHILDREN; SCREENING AND COUNSELING PPACA FOR NGP: OBESITY SCREENING IN ADULTS PPACA FOR NGP: OSTEOPOROSIS SCREENING IN WOMEN PPACA FOR NGP: OVERVIEW PPACA FOR NGP: PHENYLKETONURIA SCREENING IN NEWBORNS PPACA FOR NGP: PREGNANCY SCREENING, SEXUALLY ACTIVE FEMALES PPACA FOR NGP: PREVENTION OF FALLS IN COMMUNITY-DWELLING OLDER ADULTS PPACA FOR NGP: RH INCOMPATABILITY SCREENING PPACA FOR NGP: SERUM LIPIDS SCREENING PPACA FOR NGP: SEXUALLY TRANSMITTED INFECTIONS, BEHAVIORAL COUNSELING-PREVE PPACA FOR NGP: SICKLE CELL DISEASE, NEWBORN SCREENING PPACA FOR NGP: SKIN CANCER, COUNSELING PPACA FOR NGP: SYPHILIS SCREENING PPACA FOR NGP: TB SCREENING, INFANTS, CHILDREN & ADOLESCENTS PPACA FOR NGP: TOBACCO USE, SCREENING, COUNSELING AND INTERVENTIONS PPACA FOR NGP: TYPE 2 DIABETES MELLITUS SCREENING FOR ADULTS PPACA FOR NGP: VISUAL IMPAIRMENT SCREENING IN CHILDREN PPACA FOR NGP: WELL CHILD VISITS PPACA FOR NGP: WELL-WOMAN VISITS PPACA rule,NGP_Clinical Trials Preimplantation Genetic Diagnosis, Testing or Trtmnt Procalcitonin Prolotherapy (Sclerotherapy) Prostate Cancer Predicting Risk of Recurrence, Systems Pathology Prostate, Saturation Biopsy Prostatic Stent, Temporary Prostatic Urethral Lift (UroLift System) Proteomics Predict Response to Chemotherapy (VeriStrat) Proteomics, Evaluation of Ovarian (Adnexal) Masses (e.g., OVA1, ROMA) Proteomics, Screening and Detection of Cancer (e.g., OvaCheck) Pulmonary Arterial Hypertension, Pharm Trtmnt w Prostacyclin Analogues, ETC Pulmonary Rehabilitation Pulsed Pressure, Trtmnt for Meniere's Disease Quantitative Electroencephalography as a Diagnostic Aid for ADHD Rad Ther, Image Guidance for Prostate Cancer Rad Ther, Proton Beam for Trtmnt of Prostate Cancer Rad Ther, Proton Beam or Helium Ion Irradiation, Other than Prostate Radioactive Seed Localization of Nonpalpable Breast Lesions Radiofreq Ablation & Other Laparoscopic & Perc Techniques, Uterine Fibroids Radiofreq Ablation, Barrett's Esophagus Radiofreq Ablation, Bony Metastases Radiofreq Ablation, Breast Tumors Radiofreq Ablation, Osteoid Osteoma Radiofreq Ablation, Renal Tumors Radiofreq Trtmnt of Fecal Incontinence Radiofreq Trtmnt, Chronic Back Pain (Nucleoplasty) Radiofrequency Ablation of Peripheral Nerves to Treat Pain Radiofrequency Ablation of Primary or Metastatic Liver Tumors Radiofrequency Ablation of Renal Sympathetic Nerves, Tx for Resistant HTN Radioimmunoscintigraphy Imaging - In-111 Capromab Pendetide (ProstaScint) Radioimmunotherapy in the Trtmnt of Non-Hodgkin Lymphoma Radium Ra 223 dichloride for Symptomatic Osseous Metastatic Prostate Cancer Renal Artery, Angioplasty/Stenting, Percutaneous Repair Durable Medical Equipment (DME) and External Prosthetic Devices Repository Corticotropin Injection Respiratory Syncytial Virus Immune Prophylaxis with Palivizumab (Synagis) Responsive Neurostimulation for the Tx of Refractory Partial Epilepsy Rilonacept (Arcalyst) Rituximab (Rituxan), Off-label Use Sacral Nerve Stim Trtmnt of Fecal Incontinence Sacral Nerve Stim Trtmnt of Neurogenic Bladder Second to Spinal Cord Injury Sacral Nerve Stim Trtmnt of Urge Urinary Incontinence Sacroiliac Joint Fusion, Minimally Invasive Sacroplasty Scintimammography and Gamma Imaging of the Breast and Axilla Scleral Contact Lens, Gas Permeable Screening for Vertebral Fracture with Dual X-ray Absorptiornetry Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Sensory Integration Therapy and Auditory Integration Therapy Serum Antibodies for Diagnosis of Inflammatory Bowel Disease Short Tandem Repeat Analysis for Specimen Provenance Test (know error) Sinus Spacers and Stents, Implantable, following Endoscopic Sinus Surgery Sipuleucel-T (Provenge) for the Trtmnt of Prostate Cancer Skin and Soft Tissue Substitutes, Bio-Engineered Products Sleep Apnea & Pulmonary Disease, Ventilation Support & Resp Assist Devices Sleep Apnea, Minimally Invasive Surgical Treatment Sleep Apnea, Testing Sofosbuvir (Sovaldi) Soft Tissue Substitutes, Orthobiologic Implant Spinal Cord NeuroStim for Trtmnt of Intractable Pain Spinal Decompression Ther (Internal Disc Decompression Ther, Spinal Distrac Spinal Manipulation Under General Anesthesia Spinal Unloading Devices Trtmnt Low Back Pain (Orthotrac Pneumatic Vest) ST2 Assay for Chronic Heart Failure Stem Cell Growth Factor, Romiplostim (Nplate) Stem Cell Growth Factors, ESAs, Darbepoetin, Epoetin, Peginesatide Stereotactic Radiosurgery Gamma Knife Surg ,Linear Accelerator, Cyberknife, Subconjunctival Retinal Prosthesis Surg Deactivation of Headache Trigger Sites Surg Interruption Pelvic Nerve Pathways for Prim & Second Dysmenorrhea Surgery for Morbid Obesity Teduglutide for SBS Telemedicine Temporomandibular Joint Dysfunction Testing For Drugs of Abuse including Controlled Substances Testosterone Replacement Therapy Thermography and Infrared Dermal Thermometry Tocolysis, Acute and Maintenance Therapy Total Facet Arthroplasty Transanal Endoscopic Microsurgery (TEMS/TAMIS) Transcatheter Aortic Valve Implantation Transcatheter Arterial Chemoembolization (TACE) Treat Prim or Metas Liver Transcatheter Mitral Valve Repair Transcatheter Pulmonary Valve Implantation Transcranial Magnetic Stim Trtmnt of Depression & Other Psychiatric Disorde Transesophageal Ther GERD, Endoscopic Radiofreq Transesophageal Ther GERD, Endoscopic Suturing, Transoral Incisionless Fund Transesophageal Therapy for GERD, Endoscopic Polymer Inj., Bulking Agents Transmyocardial Laser Revascularization Transplant, Allogeneic Islet Cell or Pancreas for Diabetes Mellitus Transplant, Autologous Islet Cell for Chronic Pancreatitis Transplant, Composite Tissue Allotransplantation, Hand and/or Face Transplant, Heart Transplant, Heart/Lung Transplant, Kidney Transplant, Liver Transplant, Lung and Lobar Lung Transplant, Small Bowel Transplant, Small Bowel/Liver and Multivisceral Transpupillary Thermotherapy for Trtmnt of Choroidal Neovascularization Trastuzumab Treatment of Varicose Veins/Venous Insufficiency Tumor Antigen, CA 125 (Carcinoembryonic Antigen 125) Tumor Antigen, Prostate Specific Antigen (PSA) Tumor Markers, Urinary Bladder Cancer Tumor Vaccines Tumor-Treating Fields Therapy for Glioblastoma (NovoTTF) Ultrafiltration in Decompensated Heart Failure Under Heavy Sedation or General Anesthesia as a Tech of Opioid Detoxificati Unicondylar Interpositional Spacer Trtmnt Unicompartmental Arthritis Knee Urinary Metabolite Tests for Adherence to DAA Medications for HEP C US Accelerated Fracture Healing Device US Maternity Care US Maternity Care, 1st Trim Detect Down Syndrome-Fetal US Assess Nuchal Tra US Trtmnt for Wounds, Non-Contact Uterine Artery Embolization Trtmnt of Leiomyomas or Abnormal Uterine Bleedi Vacuum Assisted Closure Device Vagal Nerve Blocking Therapy for the Treatment of Obesity Vedolizumab (Entyvio) for Inflammatory Bowel Disease Ventricular Assist Devices Ventricular Restoration/Remodeling, Surgical Vertebroplasty, Percutaneous Vertical Expandable Prosthetic Titanium Rib Viekira Pak Virtual Colonoscopy/CT Colonography Viscocanalostomy and Canaloplasty Viscosupplementation for Trtmnt of Osteoarthritis of the Knee Whole Body Computed Tomography Scan as a Screening Test Wireless Capsule Endoscopy, Small Bowel Study, Esophagus & Colon Wireless Pressure Sensors in Endovascular Aneurysm Repair

When you select a policy, you will see its title, category and effective date at the top of the page. A description of the treatment and the actual policy, which explains what is covered, follow. At the bottom of the page, you will see related CPT codes and references.

Originally posted here:
Coverage Policy - Arkansas Blue Cross and Blue Shield