2
Psychiatric Diagnostic Evaluation and Psychotherapy Services
4
B-Type Natriuretic Peptide (BNP)
5
Bisphosphonates (Intravenous [IV]) and Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications
8
External Breast Prostheses
10
Therapeutic Shoes for Persons with Diabetes
12
Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions
13
Hospice - Determining Terminal Status
14
Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
15
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
16
Transcranial Magnetic Stimulation
17
Transcranial Magnetic Stimulation
18
EEG – Ambulatory Monitoring
19
Polysomnography and Sleep Testing
20
Surgical Management of Morbid Obesity
22
Lab: Bladder/Urothelial Tumor Markers
23
Brain Natriuretic Peptide (BNP) Level
24
Cardiac Computed Tomography & Angiography (CCTA)
25
Cosmetic and Reconstructive Surgery
27
Mohs Micrographic Surgery (MMS)
28
Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot)
29
Pulmonary Stress Testing
30
Removal of Benign and Malignant Skin Lesions
31
Respiratory Therapy and Oximetry Services
32
Special Electroencephalography
33
Swallowing Studies for Dysphagia
34
Virtual Colonoscopy (CT Colonography)
35
Wireless Gastrointestinal Motility Monitoring Systems
36
Total Joint Arthroplasty
37
Cardiac Radionuclide Imaging
39
Computerized Axial Tomography (CT), Thorax
40
Implantable Infusion Pump
41
Ophthalmology: Extended Ophthalmoscopy and Fundus Photography
42
Cardiac Catheterization and Coronary Angiography
44
Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)
45
Cardiovascular Nuclear Medicine
46
Computed Tomographic (CT) Colonography for Diagnostic Uses
47
Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
48
Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
49
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
50
B-type Natriuretic Peptide (BNP) Testing
52
Varicose Veins of the Lower Extremity, Treatment of
54
Transthoracic Echocardiography (TTE)
55
Transrectal Ultrasound
56
Transesophageal Echocardiography (TEE)
57
Speech-Language Pathology
58
Diagnostic and Therapeutic Esophagogastroduodenoscopy
59
Implantable Miniature Telescope (IMT)
60
Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
62
Autonomic Function Tests
63
Intravenous Immune Globulin
64
Oral Appliances for Obstructive Sleep Apnea
67
Osteopathic Manipulative Treatment
68
Major Joint Replacement (Hip and Knee)
69
Nonvascular Extremity Ultrasound
70
Ophthalmic Biometry for Intraocular Lens Power Calculation
72
Percutaneous Coronary Intervention
73
Psychiatric Inpatient Hospitalization
74
Psychiatric Partial Hospitalization Programs
75
Non-Invasive Vascular Studies
76
Panretinal (Scatter) Laser Photocoagulation
78
Outpatient Physical and Occupational Therapy Services
79
Psychiatry and Psychology Services
80
Magnetic Resonance Angiography (MRA)
81
Routine Foot Care and Debridement of Nails
83
Pressure Reducing Support Surfaces - Group 2
85
Duplex Scan Of Lower Extremity Arteries
87
Diagnostic Colonoscopy
89
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
90
Ankle-Foot/Knee-Ankle-Foot Orthosis
91
Ankle-Foot/Knee-Ankle-Foot Orthosis
92
Mohs Micrographic Surgery (MMS)
93
Automatic External Defibrillators
94
Pressure Reducing Support Surfaces - Group 3
95
Non-Invasive Evaluation of Extremity Veins
96
Non-invasive Extracranial Arterial Studies
97
Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries
98
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
104
Speech Generating Devices (SGD)
105
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
106
Susceptibility Studies
107
Transesophageal Echocardiogram
108
Visual Field Examination
109
Transthoracic Echocardiography (TTE)
110
Vitamin D; 25 hydroxy, includes fraction(s), if performed
111
Wireless Capsule Endoscopy
112
Heating Pads and Heat Lamps
113
High Frequency Chest Wall Oscillation Devices
114
Intrapulmonary Percussive Ventilation System
115
Lower Limb Prostheses
116
Lower Limb Prostheses
117
Manual Wheelchair Bases
118
Power Mobility Devices
119
Power Mobility Devices
120
Spinal Orthoses: TLSO and LSO
121
Spinal Orthoses: TLSO and LSO
123
Wheelchair Options/Accessories
124
Wheelchair Options/Accessories
127
External Infusion Pumps
128
External Infusion Pumps
129
Mechanical In-exsufflation Devices
130
Osteogenesis Stimulators
131
Oxygen and Oxygen Equipment
133
Respiratory Assist Devices
135
Transcutaneous Electrical Nerve Stimulators (TENS)
137
Computerized Corneal Topography
138
Destruction of Malignant Skin Lesions
139
Excision of Malignant Skin Lesions
140
Hospital Beds And Accessories
141
Negative Pressure Wound Therapy Pumps
143
Cervical Traction Devices
144
Immunosuppressive Drugs
145
Infrared Heating Pad Systems
146
Oral Anticancer Drugs
147
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
150
Pneumatic Compression Devices
151
Pneumatic Compression Devices
152
Pneumatic Compression Devices
153
Pressure Reducing Support Surfaces - Group 1
154
Pressure Reducing Support Surfaces - Group 1
157
Tracheostomy Care Supplies
158
Surgical Treatment of Nails
159
Epidural Steroid Injections for Pain Management
160
Hepatic (Liver) Function Panel
161
High Sensitivity C-Reactive Protein (hsCRP)
162
Independent Diagnostic Testing Facility (IDTF)
163
Injection of Trigger Points
165
Noninvasive Ear or Pulse Oximetry For Oxygen Saturation
166
Facet Joint Interventions for Pain Management
167
Peripheral Nerve Blocks
168
Proton Beam Radiotherapy
170
Physical Therapy - Home Health
171
B-type Natriuretic Peptide (BNP) Testing
173
Cerumen (Earwax) Removal
174
Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy
175
Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)
177
Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
178
Cardiac Event Detection
180
Somatosensory Testing
181
Cardiac Catheterization and Coronary Angiography
182
Cardiovascular Nuclear Medicine
183
Vestibular Function Tests
184
Vitamin B<sub>12</sub> Injections
185
Diagnostic Aerosol or Vapor Inhalation
187
Psychiatric Inpatient Hospitalization
188
Transcranial Doppler Studies
189
Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
190
Vitamin D Assay Testing
192
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
194
Computerized Corneal Topography
195
Treatment of Varicose Veins of the Lower Extremities
197
Parathormone (Parathyroid Hormone)
198
Sedimentation Rate, Erythrocyte
199
Trastuzumab – Trastuzumab Biologics
200
Ultrasound, Soft Tissues of Head and Neck
201
Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
204
B-type Natriuretic Peptide (BNP) Testing
205
Polysomnography and Other Sleep Studies
206
Non-Invasive Vascular Studies
207
Speech-Language Pathology
208
Outpatient Physical and Occupational Therapy Services
209
Vitamin D Assay Testing
210
Virtual Colonoscopy (CT Colonography)
212
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
213
Dialysis Access Maintenance
215
Panretinal (Scatter) Laser Photocoagulation
216
Immune Globulin Intravenous (IVIg)
217
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
219
Varicose Veins of the Lower Extremity, Treatment of
220
Transcatheter Infusion Therapy
221
Post-Void Residual Urine and/or Bladder Capacity by Ultrasound
222
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based
223
Laser Ablation of the Prostate
224
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
226
Total Hip Arthroplasty
227
Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
228
Ophthalmic Angiography (Fluorescein and Indocyanine Green)
229
Ophthalmic Biometry for Intraocular Lens Power Calculation
230
Psychiatric Inpatient Hospitalization
231
Blepharoplasty, Eyelid Surgery, and Brow Lift
232
Mohs Micrographic Surgery
233
Psychiatric Partial Hospitalization Programs
234
Removal of Benign Skin Lesions
235
Cataract Surgery in Adults
236
Treatment of Varicose Veins of the Lower Extremities
237
Trigger Point Injections
238
Diagnostic and Therapeutic Colonoscopy
240
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
242
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
243
Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
244
Routine Foot Care and Debridement of Nails
245
Pulmonary Function Testing
247
Immune Globulin Intravenous (IVIg)
249
Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography
250
Peripheral Nerve Stimulation
251
Transesophageal Echocardiography (TEE)
252
Transthoracic Echocardiography (TTE)
253
Outpatient Psychiatry and Psychology Services
254
Erythropoiesis Stimulating Agents (ESA)
255
Magnetic Resonance Angiography (MRA)
256
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
257
Ocular Photography - External
258
Visual Fields Testing
259
Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
260
B-type Natriuretic Peptide (BNP) Testing
261
Blepharoplasty, Eyelid Surgery, and Brow Lift
263
CT of the Abdomen and Pelvis
265
Homocysteine Level, Serum
266
Infrared Coagulation (IRC) of Hemorrhoids
267
Magnetic Resonance Angiography
268
Magnetic Resonance Imaging of the Orbit, Face, and/or Neck
269
Ophthalmic Angiography (Fluorescein and Indocyanine Green)
270
Outpatient Occupational Therapy
271
Outpatient Physical Therapy
272
Outpatient Speech Language Pathology
273
Respiratory Therapy (Respiratory Care)
274
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
275
Somatosensory Testing
276
Upper Gastrointestinal Endoscopy and Visualization
277
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
280
Molecular Pathology Procedures
281
Psychological and Neuropsychological Tests
283
Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder
284
Surgical Treatment of Obstructive Sleep Apnea (OSA)
285
Blepharoplasty, Blepharoptosis and Brow Lift
286
Treatment of Varicose Veins of the Lower Extremities
287
Vestibular Function Testing
288
Hospice Determining Terminal Status
289
Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians
291
Transtelephonic Spirometry
292
Hospice - Liver Disease
293
Hospice - Neurological Conditions
294
Hospice Cardiopulmonary Conditions
296
One Day Stays for Chest Pain
297
Outpatient Observation Bed/Room Services
299
In Vitro Chemosensitivity & Chemoresistance Assays
300
Hospice The Adult Failure To Thrive Syndrome
302
Home Health Occupational Therapy
303
Home Health - Psychiatric Care
304
Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances
305
Home Health Speech-Language Pathology
306
Home Health Physical Therapy
307
Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia
308
Hospice - HIV Disease
309
Hospice Alzheimer's Disease & Related Disorders
310
Psychiatric Inpatient Hospitalization
311
Cardiac Event Detection
312
Frequency of Hemodialysis
313
Laparoscopic Sleeve Gastrectomy for Severe Obesity
314
Retroperitoneal Ultrasound
315
Surface Electrical Stimulation in the Treatment of Dysphagia
316
Intravenous Immunoglobulin (IVIG)
317
Trigger Points, Local Injections
318
Nerve Conduction Studies and Electromyography
320
Colonoscopy and Sigmoidoscopy-Diagnostic
322
Psychiatry and Psychology Services
323
Intraoperative Neurophysiological Testing
324
Somatosensory Testing
325
Erythropoiesis Stimulating Agents (ESAs)
326
Botulinum Toxin Type A & Type B
327
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
328
Transcranial Magnetic Stimulation (TMS)
329
Transcranial Magnetic Stimulation (TMS)
331
Psychological and Neuropsychological Testing
332
Bisphosphonate Drug Therapy
333
Vitamin D Assay Testing
334
Endoscopic Treatment of GERD
335
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
336
Percutaneous Coronary Interventions
338
Transcutaneous Electrical Joint Stimulation Devices (TEJSD)
339
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
340
Tumor Treatment Field Therapy (TTFT)
341
Vacuum Erection Devices (VED)
342
Cardiac Rhythm Device Evaluation
343
Blood Glucose Monitoring in a Skilled Nursing Facility (SNF)
344
C-Reactive Protein High Sensitivity Testing (hsCRP)
345
Nerve Conduction Studies and Electromyography
346
Loss-of-Heterozygosity Based Topographic Genotyping with PathfinderTG<sup> ®</sup>
347
Magnetic Resonance Angiography (MRA)
348
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults
349
Surgical Treatment of Nails
350
Facet Joint Interventions for Pain Management
351
Genetic Testing for Lynch Syndrome
352
Assays for Vitamins and Metabolic Function
353
Treatment of Chronic Venous Insufficiency of the Lower Extremities
354
Removal of Benign Skin Lesions
355
Mohs Micrographic Surgery (MMS)
356
Neurophysiology Evoked Potentials (NEPs)
357
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
358
Neuromuscular Junction Testing
359
Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder
360
Molecular Pathology Procedures
361
Reduction Mammaplasty
362
Intraoperative Neurophysiological Testing
363
Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
364
Controlled Substance Monitoring and Drugs of Abuse Testing
365
Vestibular and Audiologic Function Studies
366
Trigger Point Injections
367
Debridement of Mycotic Nails
368
Frequency of Hemodialysis
369
Transesophageal Echocardiography (TEE)
370
Bariatric Surgical Management of Morbid Obesity
371
MolDX: Molecular Diagnostic Tests (MDT)
373
Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency
374
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography
375
Scanning Computerized Ophthalmic Diagnostic Imaging
376
Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
377
Nerve Conduction Studies and Electromyography
378
Monitored Anesthesia Care
379
Outpatient Sleep Studies
381
Speech - Language Pathology (SLP) Services: Communication Disorders
382
MolDX: NRAS Genetic Testing
385
Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
386
Select Minimally Invasive GERD Procedures
387
Nerve Conduction Studies and Electromyography
388
Cardiology Non-emergent Outpatient Stress Testing
389
Wireless Capsule Endoscopy
390
Cosmetic and Reconstructive Surgery
391
Cataract Extraction (including Complex Cataract Surgery)
392
Diagnostic Abdominal Aortography and Renal Angiography
394
Nerve Conduction Studies and Electromyography
395
Frequency of Laboratory Tests
397
Implantable Infusion Pump
398
Coronary Computed Tomography Angiography (CCTA)
399
Autonomic Function Testing
401
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
402
Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus
403
Spinal Cord Stimulators for Chronic Pain
405
MolDX: Molecular Diagnostic Tests (MDT)
407
Botulinum Toxin Types A and B Policy
408
Botulinum Toxin Types A and B
409
MRI and CT Scans of the Head and Neck
410
Nerve Blocks for Peripheral Neuropathy
411
Nerve Blocks for Peripheral Neuropathy
412
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
413
Multiple Imaging in Oncology
414
Autonomic Function Tests
415
Biomarkers for Oncology
416
Non-Invasive Cerebrovascular Arterial Studies
419
MolDX: NRAS Genetic Testing
420
Independent Diagnostic Testing Facility (IDTF)
421
Non-Invasive Peripheral Venous Studies
422
Nerve Blockade for Treatment of Chronic Pain and Neuropathy
423
Nerve Blockade for Treatment of Chronic Pain and Neuropathy
424
Pelvic Floor Dysfunction: Anorectal Manometry and EMG
426
Mohs Micrographic Surgery
427
Removal of Benign Skin Lesions
428
B-type Natriuretic Peptide (BNP) Testing
430
Mohs Micrographic Surgery
431
Mohs Micrographic Surgery
433
Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
434
Non-Invasive Cerebrovascular Studies
435
Non-Invasive Abdominal / Visceral Vascular Studies
436
Non-Invasive Peripheral Arterial Vascular Studies
437
Intravenous Immune Globulin
438
Nerve Conduction Studies and Electromyography
439
Somatosensory Testing
440
Lab: Special Histochemical Stains and Immunohistochemical Stains
441
Lab: Special Histochemical Stains and Immunohistochemical Stains
442
Facet Joint Interventions for Pain Management
443
MolDX: MGMT Promoter Methylation Analysis
444
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
445
Special Histochemical Stains and Immunohistochemical Stains
446
Non-Coronary Vascular Stents
447
Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
448
MolDX: ConfirmMDx Epigenetic Molecular Assay
449
Lower Extremity Major Joint Replacement (Hip and Knee)
450
MolDX: Molecular Diagnostic Tests (MDT)
453
Total Joint Arthroplasty
454
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
455
MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
457
MolDX: MGMT Promoter Methylation Analysis
458
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
459
MolDX: Breast Cancer Assay: Prosigna®
460
MolDX: Biomarkers in Cardiovascular Risk Assessment
461
MolDX: Biomarkers in Cardiovascular Risk Assessment
462
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
463
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
464
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
465
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
466
MolDX: MGMT Promoter Methylation Analysis
467
MolDX: MGMT Promoter Methylation Analysis
468
Spinal Cord Stimulators for Chronic Pain
469
Special Histochemical Stains and Immunohistochemical Stains
470
Autonomic Function Testing
471
Allergen Immunotherapy
473
MolDX: Molecular Diagnostic Tests (MDT)
474
Bowel Management Devices
475
Blepharoplasty, Eyelid Surgery, and Brow Lift
476
MolDX: NRAS Genetic Testing
477
MolDX: NRAS Genetic Testing
478
Lab: Special Histochemical Stains and Immunohistochemical Stains
479
Lab: Special Histochemical Stains and Immunohistochemical Stains
480
Lab: Special Histochemical Stains and Immunohistochemical Stains
481
Lab: Special Histochemical Stains and Immunohistochemical Stains
482
MolDX: Biomarkers in Cardiovascular Risk Assessment
483
MolDX: Biomarkers in Cardiovascular Risk Assessment
484
Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities
485
MolDX: Breast Cancer Assay: Prosigna®
486
MolDX: Breast Cancer Assay: Prosigna®
487
Controlled Substance Monitoring and Drugs of Abuse Testing
488
MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
490
Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
491
Allergy Immunotherapy
492
MolDX: Breast Cancer Assay: Prosigna®
493
Wireless Capsule Endoscopy
494
Bone Mass Measurement
495
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
496
Transcranial Magnetic Stimulation (TMS)
497
Transcranial Magnetic Stimulation (TMS)
498
<b> MolDX: HLA-DQB1*06:02 Testing for Narcolepsy</b>
499
Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
500
BRCA1 and BRCA2 Genetic Testing
501
MolDX: Biomarkers in Cardiovascular Risk Assessment
502
Nerve Conduction Studies and Electromyography
503
Nerve Conduction Studies and Electromyography
504
Treatment of Males with Low Testosterone
505
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
506
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
507
Treatment of Males with Low Testosterone
508
Total Hip Arthroplasty
509
Total Knee Arthroplasty
510
Total Knee Arthroplasty
516
Lab: Bladder/Urothelial Tumor Markers
517
Lab: Bladder/Urothelial Tumor Markers
518
Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities
519
Vitamin D Assay Testing
525
Intensity Modulated Radiation Therapy (IMRT)
526
BRCA1 and BRCA2 Genetic Testing
527
GlycoMark® Testing for Glycemic Control
529
Aortography and peripheral angiography
530
Intensity Modulated Radiation Therapy (IMRT)
531
MolDX: NRAS Genetic Testing
532
Lab: Special Histochemical Stains and Immunohistochemical Stains
533
MolDX: Molecular Diagnostic Tests (MDT)
534
MolDX: Breast Cancer Assay: Prosigna®
535
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
536
Visual Electrophysiology Testing
537
Polysomnography and Other Sleep Studies
538
Measurement of Salivary Hormones
539
Peripheral Nerve Blocks
540
MolDX: Percepta® Bronchial Genomic Classifier
541
Measurement of Salivary Hormones
542
Trigger Point Injections
543
Polysomnography and Other Sleep Studies
544
GlycoMark® Testing for Glycemic Control
545
GlycoMark® Testing for Glycemic Control
546
Diagnostic and Therapeutic Colonoscopy
547
MolDX: Percepta© Bronchial Genomic Classifier
548
Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography
549
MolDX: Percepta© Bronchial Genomic Classifier
550
Polysomnography and Other Sleep Studies
551
GlycoMark® Testing for Glycemic Control
552
MolDX: Percepta® Bronchial Genomic Classifier
553
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
554
Epidural Steroid Injections for Pain Management
555
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
556
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
557
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
558
Bladder/Urothelial Tumor Markers
559
MolDX: MGMT Promoter Methylation Analysis
560
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
562
Visual Electrophysiology Testing
564
Lab: Coenzyme Q10 (CoQ10)
565
Cataract Surgery in Adults
567
MolDX: DecisionDx-UM (Uveal Melanoma)
570
Lab: Coenzyme Q10 (CoQ10)
571
Lab: Coenzyme Q10 (CoQ10)
572
MolDX: DecisionDx-UM (Uveal Melanoma)
573
MolDX: DecisionDx-UM (Uveal Melanoma)
574
Transcranial Magnetic Stimulation (TMS)
575
Transcranial Magnetic Stimulation (TMS)
576
Transcranial Magnetic Stimulation (TMS)
577
Transcranial Magnetic Stimulation (TMS)
579
MolDX: DecisionDx-UM (Uveal Melanoma)
581
White Cell Colony Stimulating Factors
582
MolDX: Percepta® Bronchial Genomic Classifier
583
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
584
Chemotherapy Drugs and their Adjuncts
585
MolDX: Decision Dx-UM (Uveal Melanoma)
588
Micro-Invasive Glaucoma Surgery (MIGS)
589
Chiropractic Services
590
MolDX: Prometheus IBD sgi Diagnostic® Policy
591
MolDX: EndoPredict Breast Cancer Gene Expression Test
595
MolDX: EndoPredict® Breast Cancer Gene Expression Test
596
MolDX: Prometheus IBD sgi Diagnostic® Policy
597
MolDX: EndoPredict® Breast Cancer Gene Expression Test
598
MolDX: Prometheus IBD sgi Diagnostic® Policy
599
MolDX: Prometheus IBD sgi Diagnostic® Policy
600
MolDX: EndoPredict Breast Cancer Gene Expression Test
601
Peripheral Nerve Stimulation
602
Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)
603
Electroretinography (ERG)
604
MRI and CT Scans of the Head and Neck
606
Chiropractic Services
607
Electroretinography (ERG)
608
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor
609
Frequency of Hemodialysis
610
Prostate Rectal Spacers
611
Frequency of Hemodialysis
612
Frequency of Hemodialysis
613
Micro-Invasive Glaucoma Surgery (MIGS)
614
Vitamin D Assay Testing
615
Frequency of Hemodialysis
616
MolDX: Prometheus IBD sgi Diagnostic® Policy
619
Cystatin C Measurement
620
Frequency of Hemodialysis
621
Frequency of Hemodialysis
622
Micro-Invasive Glaucoma Surgery (MIGS)
623
Lab: Cystatin C Measurement
624
Cystatin C Measurement
626
Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
628
Lab: Cystatin C Measurement
629
Lab: Cystatin C Measurement
632
In Vitro Chemosensitivity & Chemoresistance Assays
633
In Vitro Chemosensitivity & Chemoresistance Assays
634
Spinal Cord Stimulators for Chronic Pain
635
Partial Hospitalization Programs
636
Trigger Point Injections
637
Nonobstetric Pelvic Ultrasound
638
Health and Behavior Assessment/Intervention
639
Continuous Peripheral Nerve Blocks (CPNB)
640
Nerve Blocks and Electrostimulation for Peripheral Neuropathy
643
MolDX: EndoPredict® Breast Cancer Gene Expression Test
644
MolDX: Melanoma Risk Stratification Molecular Testing
645
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease
646
Biomarker Testing for Prostate Cancer Diagnosis
647
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease
648
MolDX: Melanoma Risk Stratification Molecular Testing
649
MolDX: Melanoma Risk Stratification Molecular Testing
650
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
652
Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication
653
Intraoperative Radiation Therapy
654
Magnetic Resonance Guided Focused Ultrasound Surgery System (MRgFUS) for the treatment of neurologic conditions
655
4Kscore Test Algorithm
656
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
657
4Kscore Test Algorithm
658
Allergen Immunotherapy
659
Water Vapor Thermal Therapy for LUTS/BPH
660
Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms
661
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
662
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
663
Lumbar Artificial Disc Replacement
664
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
666
Biomarker Testing for Neuroendocrine Tumors/Neoplasms
667
MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
668
Voretigene Neparvovec-rzyl (Luxturna®)
669
MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
670
Topical Oxygen Therapy
671
MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
672
MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
674
MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
675
MolDX: Inivata™, InvisionFirst®, Liquid Biopsy for Patients with Lung Cancer
676
MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
677
MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
678
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
679
MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
680
MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
682
MolDX: Melanoma Risk Stratification Molecular Testing
683
MolDX: Melanoma Risk Stratification Molecular Testing
685
Cervical Disc Replacement
686
MolDX: Plasma-Based Genomic Profiling in Solid Tumors
687
MolDX: Next-Generation Sequencing for Solid Tumors
688
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
689
MolDX: Pigmented Lesion Assay
690
MolDX: Plasma-Based Genomic Profiling in Solid Tumors
691
MolDX: Next-Generation Sequencing for Solid Tumors
692
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
693
MolDX: Pigmented Lesion Assay
694
MolDX: Next-Generation Sequencing for Solid Tumors
695
MolDX: Next-Generation Sequencing for Solid Tumors
696
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
697
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
698
MolDX: Pigmented Lesion Assay
699
MolDX: Pigmented Lesion Assay
700
MolDX: Next-Generation Sequencing for Solid Tumors
701
MolDX: Plasma-Based Genomic Profiling in Solid Tumors
702
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
703
MolDX: Pigmented Lesion Assay
704
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
706
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
707
Micro-Invasive Glaucoma Surgery (MIGS)
708
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)
709
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)
711
Micro-Invasive Glaucoma Surgery (MIGS)
712
Micro-Invasive Glaucoma Surgery (MIGS)
713
MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
714
MolDX: Blood Product Molecular Antigen Typing
715
MolDX: Blood Product Molecular Antigen Typing
716
Immune Thrombocytopenia (ITP) Therapy
717
MolDX: Repeat Germline Testing
718
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
719
Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease
720
MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer
721
MolDX: Repeat Germline Testing
722
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
723
MolDX: Pharmacogenomics Testing
724
Micro-Invasive Glaucoma Surgery (MIGS)
725
Micro-Invasive Glaucoma Surgery (MIGS)
726
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
727
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
728
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
729
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
730
MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
731
MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
732
MolDX: Blood Product Molecular Antigen Typing
733
MolDX: Blood Product Molecular Antigen Typing
734
MolDX: Pharmacogenomics Testing
735
MolDX: Pharmacogenomics Testing
736
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
737
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
738
MolDX: Repeat Germline Testing
739
MolDX: Repeat Germline Testing
740
Fluid Jet System Treatment for LUTS/BPH
741
Multimarker Serum Tests Related to Ovarian Cancer Testing
742
Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)
743
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
744
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
745
MolDX: Pharmacogenomics Testing
746
Cardiology Non-emergent Outpatient Stress Testing
747
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
748
MolDX: Repeat Germline Testing
749
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
750
MolDX: Pharmacogenomics Testing
751
MolDX: Blood Product Molecular Antigen Typing
752
MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
753
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
754
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
755
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
756
Transurethral Waterjet Ablation of the Prostate
757
Transanal Endoscopic Surgery (TES)
758
MolDX: Phenotypic Biomarker Detection in Circulating Tumor Cells
759
MolDX: Molecular Testing for Solid Organ Allograft Rejection
760
Colon Capsule Endoscopy (CCE)
761
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
762
MolDX: Molecular Testing for Solid Organ Allograft Rejection
763
MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
764
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
765
Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
766
Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
767
Implantable Continuous Glucose Monitors (I-CGM)
768
Implantable Continuous Glucose Monitors (I-CGM)
769
MolDX: Molecular Testing for Solid Organ Allograft Rejection
770
MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
771
MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
772
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
773
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
774
Implantable Continuous Glucose Monitors (I-CGM)
775
Implantable Continuous Glucose Monitors (I-CGM)
776
Implantable Continuous Glucose Monitors (I-CGM)
777
Implantable Continuous Glucose Monitors (I-CGM)
778
Computed Tomography Cerebral Perfusion Analysis (CTP)
779
MolDX: Molecular Testing for Solid Organ Allograft Rejection
780
MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
781
MolDx: Molecular Testing for Solid Organ Allograft Rejection
782
Transurethral Waterjet Ablation of the Prostate
783
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
784
Implantable Continuous Glucose Monitors (I-CGM)
785
Computed Tomography Cerebral Perfusion Analysis (CTP)
786
Computed Tomography Cerebral Perfusion Analysis (CTP)
787
Transurethral Waterjet Ablation of the Prostate
788
Transurethral Waterjet Ablation of the Prostate
789
Computed Tomography Cerebral Perfusion Analysis (CTP)
790
Transurethral Waterjet Ablation of the Prostate
791
Treatment of Chronic Venous Insufficiency of the Lower Extremities
792
Transurethral Waterjet Ablation of the Prostate
793
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
794
Implantable Continuous Glucose Monitors (I-CGM)
796
Peroral Endoscopic Myotomy (POEM)
797
Colon Capsule Endoscopy (CCE)
798
Facet Joint Interventions for Pain Management
799
Computed Tomography Cerebral Perfusion Analysis (CTP)
800
Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
801
Facet Joint Interventions for Pain Management
802
Extracorporeal Shock Wave Therapy (ESWT)
803
Colon Capsule Endoscopy (CCE)
804
MolDX: Minimal Residual Disease Testing for Cancer
805
Echocardiography for Myocardial Perfusion
806
Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®)
807
Facet Joint Interventions for Pain Management
808
Facet Joint Interventions for Pain Management
809
Colon Capsule Endoscopy (CCE)
810
Colon Capsule Endoscopy (CCE)
