ASM | ACGHolmes

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ACG

h.o.l.M.E.S.

Automated Clinical Guidelines

ASM (Ambulatory Specialty Model)

Cardo2.tif

Heart Failure:

Cardiac Diagnosis, Medication, & Treatment

BCBSIL
BCBSMT
BCBSNM
BCBSOK
BCBSTX

Ambulatory Cardiac Rhythm Monitoring

Ankle Brachial Index (ABI)

Automated Ambulatory Blood Pressure Monitoring (APBM)

Ambulatory External & Implantable Electrocardio-graphic Monitoring

Cardiac Electrophysiological (EP) Studies

Cardiac Event Detection Monitoring

Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB)

Anthem

MA

FloridaBlue

Aetna

Cigna

MA

FloridaBlue

FloridaBlue

MA

Medicare

Cigna

United

Cardiac Telemetry

Cardiology Non-emergent Outpatient Stress Testing

Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, Pacemaker
Monitors

Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress & Stress Echocardiography

Device Physiologic CV Data Element Interrogation

Electrocardiograms

MA

Medicare

MA

FEP

Aetna

MA

Electrophysiology Study with Arrhythmia Induction

Stress Echocardiography

Enhanced External Counterpulsation (EECP)

Holter Monitor

MA

FloridaBlue

Anthem

Aetna

MA

Long-Term Wearable Electrocardiographic Monitoring (WEM)

Microvolt
T-Wave Alternans

Cardiology Non-emergent Outpatient Stress Testing

Noninvasive Tests of Carotid Function

Non-Invasive Programmed Stimulation of AICD

Patient Activated Event Recorder

Perioperative Cardiovascular Evaluation Care Before Noncardiac Surgery

Medicare

MA

MA

MA

Real-Time, Outpatient Cardiac Telemetry

Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs)

Tilt Table Testing

Transtelephonic Monitoring of Cardiac Pacemakers

Aetna

Humana

MA

Interventional Cardiology

Acute Ischemic Stroke Treatments

Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

Angioplasty (Extracranial, Intracranial) & Intracranial Aneurysm Repair

Aorta Coronary Bypass Surgery (CABG)

Aortic Valve Replacement

Aorto-Renal Endarterectomy or Bypass Surgery

Aetna

Anthem

Cigna

MA

MA

MA

Arterial Intervention

Ascending Aortic Graft Surgery

Automatic Implantable Cardioverter Defibrillator

Balloon-Expandable Venous Stents

Balloon Valvuloplasty

Biventricular Pacing/Cardiac Resynchronization Therapy

Cardiac Catheter Ablation

Cigna

MA

Aetna

Aetna

Aetna

Aetna

MA

FEP

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Cardiac Catheterization

Cardiac Electrophysiological (EP) Studies

Cardiac PET with CT for Attenuation

Cardiac Resynchronization Therapy (CRT)

Cardiac Resynchronization Therapy & Other Pacing/Defibrillator Treatments for Heart Failure

Carotid, Vertebral & Intracranial Artery Stent Placement with or without Angioplasty

Catheter Based Carotid Artery Digital Angiography

Humana

Anthem

Cigna

MA

Anthem

Cigna

Anthem

MA

Coronary Artery Brachytherapy & Other Adjuncts to Coronary Interventions

Coronary Atherectomy

Coronary Intra Vascular Arterial Ultrasound

Descending Thoracic Aortic Graft Surgery

Diagnostic Coronary Angiography

Dialysis Access Evaluation

Drug-eluting Stents

MA

Aetna

MA

MA

FloridaBlue

Anthem

Anthem

Aetna

Dual Chamber Pacemakers

Elective Percutaneous Coronary Intervention

Embolization Procedures

Endomyocardial Biopsy

Endovascular Femoropopliteal Interventions

Endovascular Procedures for Intracranial Arterial Disease

Endovascular Revascularization (Lower Extremities)

FloridaBlue

Aetna

MA

MA

FloridaBlue

FEP

Anthem

Endovenous Stenting

EPS with AI for AFib AVN & AP Ablation

EPS with AI, Pacing after DI & Atrial or SVT & AP Ablation

Cardiac Electrophysiological Studies (EPS) & Catheter Ablation

Extracranial Carotid Angioplasty/ Stenting

Medicare

EPS with Transseptal Left Heart Cath with Arrhythmia Induction & VT Ablation

Implantable Cardioverter Defibrillators

MA

MA

MA

Anthem

FloridaBlue

Anthem

FEP

FloridaBlue

Implantation of Loop Recorder Systems

Intervention on Adults with Congenital Heart Defects

Intra Cardiac Echocardiography (ICE)

Intracardiac Electrophysiological Studies (EPS) & Catheter Ablation

Intraoperative Ventricular Mapping

Intravascular Coronary Brachytherapy

Leadless Cardiac Pacemakers

MA

MA

MA

Humana

Aetna

Aetna

FEP

Left Atrial Appendage & Cardiac Structural Defect Closure

Lower Extremity Endovascular Procedures

Mitral Valve Surgery

Mechanical Embolectomy for Treatment of Acute Stroke

Non-coronary Vascular Stents: Brachiocephalic Arteries

Non-coronary Vascular Stents: Lower Extremity Arteries

Non-coronary Vascular Stents: Pulmonary Artery

United

MA

United

Anthem

Medicare

Medicare

Medicare

Non-coronary Vascular Stents: Renal Artery

Non-coronary Vascular Stents: Venous Stents

Non-coronary Vascular Stents: Mesenteric Vessels

Nonpharmacological Treatment for Atrial Fibrillation

Pacemakers

Medicare

Medicare

Anthem

Catheter Based Closure of Patent Foramen Ovale

Percutaneous Closure of Patent Foramen Ovale (PFO)

Medicare

Cigna

MA

Cigna

Anthem

MA

Percutaneous Coronary Intervention

Percutaneous Iliocaval Interventions

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)

Pericardial Disease Interventions

Peripheral Atherectomy & Thrombectomy Devices

Peripheral Vascular Stents

FloridaBlue

Anthem

MA

FloridaBlue

Aetna

MA

Aetna

MA

Medicare

Humana

Phrenic Nerve Stimulator
(NCD 160.19)

Renal Angiography

Renal Artery Intervention

Single Chamber Pacemaker

Stenting for Iliac Vein Compression for May-Thurner Syndrome

Subcutaneous ICD Device Implantation & Removal

Synchronized Electrical Cardioversion

Temporal Artery Biopsy

MA

MA

MA

MA

MA

MA

Aetna

Thrombectomy Systems

Transcatheter Ablation for Management of Atrial Fibrillation

Transcatheter Ablation for the Treatment of Supraventricular & Ventricular Arrhythmias

Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins

Transcatheter Aortic Valve Implantation - Replacement

Transcatheter Closure of Cardiovascular Defects

Transcatheter Closure of Septal Defects

Aetna

Anthem

Anthem

Cigna

Anthem

FloridaBlue

Humana

Cigna

Humana

Aetna

FloridaBlue

Transcatheter Edge to Edge Repair (TEER) of Mitral Valve

Transcatheter Heart Valve Procedures

Transcatheter Intravascular Stents

Transcatheter Mitral Valve Repair

Transcatheter Placement of Intracranial Stent

Transcatheter Procedures for Heart Valve Conditions

Transcatheter Pulmonary Valve Implantation

MA

Anthem

Cigna

Humana

FEP

FloridaBlue

United

Medicare

Humana

UHC

Humana

Transcatheter Valve Procedures

Transcoronary Ablation of Septal Hypertrophy (TASH)

Treatment for Varicose Veins & Venous Insufficiency

Treatment for Varicose Veins & Venous Insufficiency

Tricuspid Valve Surgery

T-Wave Alternans

Vascular Embolization & Occlusion

Humana

FloridaBlue

MA

Aetna

UHC

Cigna

Anthem

Medicare

Vascular Stenting of Lower Extremity Arteries

Vena Cava Filters

Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

Ventricular Assist Device (VAD), Percutaneous & Permanent

Ventricular Assist Devices (VADs), Percutaneous Cardiac Support Systems & Total Artificial Heart

Wearable & Non-Wearable Cardioverter Defibrillators (WCD) for the Prevention of Sudden Cardiac Death

Wireless Pulmonary Artery Pressure Device Placement & Monitoring

MA

Cigna

MA

Cigna

FEP

Cigna

Anthem

MA

FloridaBlue

Imaging

Abdominal Aortic Aneurysm Screening

Aortography & Peripheral Angiography Thoracic & Carotid Aortography

Arterial Duplex

MA

Arterial PVR & Stress Arterial PVR

Cardiac Catheterization

Cardiac Imaging

Cardiac Imaging

Aetna

MA

Humana

Anthem

Aetna

BCBSMI

Cigna

BCBSNJ

BCBSNC

United

BCBSTX

FloridaBlue

MassBlue

Cardiac Magnetic Resonance Imaging

Cardiac PET

FloridaBlue

Cardiac Single-Photon Emission Computed Tomography (SPECT)

Cardiovascular Nuclear Medicine - Cardiac Blood Pool Studies

Cardiovascular Nuclear Medicine - Infarct Avidity Studies

Cardiovascular Nuclear Medicine - Perfusion with or without Functional Studies

Color-Flow Doppler Echocardiography in Adults

FloridaBlue

Cigna

MA

Humana

Computed Tomographic Angiography (CTA) Heart

Coronary Artery Calcium Scoring and Coronary Computed Tomography Angiography

Coronary & Cardiac Computed Tomographic Angiography

Cardiac Computed Tomography (CCT) & Coronary Computed Tomography Angiography (CCTA)

Coronary Artery Calcium Scoring by Electron-Beam Tomography or Non-Contrast Coronary CT

CT Heart

FloridaBlue

Duplex Scan of Hemodialysis Access

FloridaBlue

FEP

MA

MA

MA

Humana

Duplex Scanning of Aorta, Inferior Vena Cava, Iliac Vasculature, or Bypass Grafts

Echocardio-graphy

Echocardiography done with Ultrasound Enhancing Agent (UEA)

Fractional Flow Reserve CT

Intracoronary Doppler Ultrasound

Magnetic resonance imaging (MRI) of the cardiovascular system

MRI of the Heart

FloridaBlue

FEP

MA

Aetna

MUGA Scan

Myocardial Perfusion Imaging

Pharmacological Nuclear Stress Test/Myocardial Perfusion Imaging (MPI)

Radionuclide Angiography (MUGA SCAN)

Stress Echocardio-graphy

Transesophageal Echocardiography (TEE)

FloridaBlue

FloridaBlue

MA

MA

Transthoracic Echocardiography (TTE)

Ultrasound-Guided Vascular Access

Venous Duplex

Vessel Mapping for Hemodialysis Access or CABG PAD Surgery

Cigna

MA

MA

MA

MA

Indicates Non-covered Service

Absolute Quantitation of Myocardial Blood Flow Measurement

Intracardiac Ischemia Monitoring

Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure

Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management

Signal Averaged Electrocar-diography (SAECG)

Ultrafiltration in Decompensated Heart Failure

Anthem

Anthem

FloridaBlue

Anthem

Anthem

Low Back Pain:

Interventional Pain Management

Aetna

Acupuncture

Aetna

Acupuncture forChronic Low Back Pain (cLBP)

Back Pain - Invasive Procedures

Botulinum Toxins

Continuous Peripheral Nerve Blocks (CPNB)

Dorsal Column Stimulation

Electric Stimulation for Pain, Swelling and Function in a Clinic Setting

Anthem

BlueMich

Cigna

Humana MA

Medicare

MA

Aetna

HN

Cigna

UHC MA

Transforaminal Epidural Injections

Selective Nerve Root Blocks
& Transforaminal Epidural Steroid Injections

Epidural Injections

Epidural & Selective Nerve RootBlock (SNRB)

Epidural Steroid Injections for Spinal Pain

Epidural Patching

Aetna

Epidural Steroid Injections for Pain Management excluding facet joint injections (L39015, L33906, L39036, L39240, L39242, L36920, L38994, L39054)

Aetna

FloridaBlue

Cigna

Medicare

UHC

Extended Release Opioids

Opioid Days' Supply Limitation

Radiofrequency Joint Ablation/
Denervation

Facet Joint Interventions

Facet Joint Interventions for Pain Management

Facet Joint Injections

Facet Joint Injections/Medial Branch Blocks

Humana

Cigna

FEP

Medicare

FloridaBlue

Cigna

Facet Joint Injections for Spinal Pain

Implantable Infusion Pumps for Pain or Spasticity

Injection of Morton's neuroma

Injections for Chronic Pain Conditions

Nerve Blockade for Treatment of Chronic Pain & Neuropathy

Nerve Block Injections

Ablative Treatment for Spinal Pain

UHC

Humana

Aetna

UHC

Monitored Anesthesia Care (MAC)
Interventional Pain Management Procedures Adults

Moderate Sedation for Interventional Pain Management Procedures Adults

Neuroablative Techniques for Chronic Pain

Peripheral Nerve Blocks

Percutaneous Electrical Nerve Stimulation (PENS)

Percutaneous Vertebral Disc & Vertebral Endplate Procedures

Post-Herpetic Neuralgia Treatment

FloridaBlue

Cigna

Humana

Medicare

FloridaBlue

Cigna

Anthem

Aetna

Sacroiliac Joint Injections

FloridaBlue

Cigna

Spasticity Management

Spinal Cord Stimulation

Spinal Cord Stimulation for Chronic Pain

Spinal Cord & Dorsal Root Ganglion Stimulation

Tendon Sheath & Ligament Injections

Transcutaneous Electric Nerve Stimulation (TENS)

Trigger Point Injections

Aetna

Humana

Anthem

Aetna

Medicare

FloridaBlue

FloridaBlue

Cigna

FloridaBlue

FEP

FloridaBlue

UHC

Minimally Invasive Spine Surgery Procedures & Trigger Point Injections

Visco-supplementation

Visco-supplementation
for Osteoarthritis

Aetna

Cigna

Humana

Cigna

Cigna

Humana Medicaid

Medicare

UHC

Indicates Non-covered Service

Anesthetic & Antiemetic Infusion Pumps

Discogenic

Pain

Treatment

Epidural Adhesiolysis

Headache & Occipital Neuralgia Treatment

Headaches: Invasive Procedures

Intra-oral Appliances for Headaches & Trigeminal Neuralgia

Orthopedic Applications of Stem-Cell Therapy

Aetna

UHC

FloridaBlue

Cigna

Aetna

FloridaBlue

Cigna

Aetna

FloridaBlue

Cigna

Intravenous Lidocaine for the Management of Chronic Pain

Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation

Surface Scanning & Macro Electromy-ography

Ultrasound Guidance Trigger Point injections

Visco-

supplements

FloridaBlue

Cigna

Aetna

Cigna

FloridaBlue

Spine Surgery

Anterior Cervical Decompression with Fusion (ACDF) - Single Level (elective)

Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)

Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)

Anterior Vertebral Body Tethering

Back Pain - Invasive Procedures

Cervical Decompression with or without Fusion

Cervical Fusion

Aetna

Aetna

Cigna

cervicalspinalfusion copy.png

Cervical Fusion for Treatment of Axial Neck Pain (elective)

Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)

Cervical Disc Replacement

Aetna

Cervical laminectomy for herniated disc

Cervical Laminoplasty

Cervical Plexus Block

Cervical Posterior Decompression (elective)

Anthem

Aetna

Cigna

FloridaBlue

Cigna

Aetna

Humana

MA

Point32Health

Medicare

UHC

Cervical Posterior Decompression with Fusion - Multiple Levels (urgent/

emergent)

Cervical Posterior Decompression with Fusion-Single Level (elective)

Referral Indications- Cervical Spine

Cervical Spine Procedures

Coccygectomy & Treatments for Coccydynia

Discography- Lumbar

Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

Anthem

Aetna

FloridaBlue

Cigna

Humana

FEP

Sacral Nerve Stimulation

Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406)

Sacroiliac Joint Fusion

Sacroiliac Joint Procedures

Scoliosis and Spinal Deformity

Scoliosis Surgery (Vertebral Body Tethering)

Single Level Lumbar Fusion with or without decompression (elective)

FloridaBlue

Medicare

Anthem

Cigna

Medicare

FloridaBlue

Anthem

Lumbar Discectomy/ Microdiscectomy (elective)

Lumbar Spinal Fusion

Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)

Referral Indications Lumbar Spine

Lumbar Spinal Procedures

Lumbar Total Disc Arthroplasty (TDA)

Anthem

Medicare

Anthem

Anthem

FloridaBlue

Anthem

Medicare

UHC

Multi-level Lumbar Fusions with or without decompression (elective)

Pedicle screws for spinal fixation and intervertebral body fusion devices

Percutaneous Vertebral Augmentation

Percutaneous Vertebral Disc and Vertebral Endplate Procedures

Recombinant Human Bone Morphogenetic Protein (BMP)

Repeat Lumbar Spine Fusion Operations (elective)

Anthem

FloridaBlue

Humana

Anthem

FloridaBlue

Growing Rods for Spinal Surgery

Idiopathic Scoliosis Treatment

Interspinous Process Decompression

Intervertebral Disc Prostheses

Laminectomy, Laminotomy, Facetectomy, & Foraminotomy (elective)

Laminectomy and Fusion

Lumbar Laminectomy

Aetna

Medicare

Aetna

Anthem

Aetna

Anthem

FEP

Cigna

Humana

Spinal Decompression Surgery

Surgery for Spinal Deformity

Surgical Treatment of Chest Wall Deformities

Spinal Fusion Surgery- All Levels

Thoracic laminectomy and/or thoracic diskectomy and fusion

Thoracic laminectomy and/or thoracic diskectomy and fusion

Thoracoscopic Sympathectomy

Humana

FloridaBlue

Cigna

Aetna

Humana

UHC

Indicates Non-covered Service

Automated Percutaneous Discectomy, Laser Discectomy, Percutaneous Endoscopic Discectomy, & DISC Nucleoplasty

Axial LIF

Aetna

Discography

UHC

Dynamic Spinal Stabilization Devices

Epidural Lysis of Adhesions

Epiduroscopy

Humana

UHC

Facet Arthroplasty

FloridaBlue

FloridaBlue

Interspinous & Interlaminar Stabilization/Distraction (Spacers) & Fixation (Fusion) Devices

Intradiscal Procedures

Aetna

Lumbar Total Disc Arthroplasty (TDA)

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofre-quency Annuloplasty, & Biacuplasty

Pulsed Radiofrequency

Aetna

Skeletal Analysis Systems

Traction Devices – Cervical & Lumbar

FEP Blue

Aetna

Aetna

FloridaBlue

Cigna

FloridaBlue

Cigna

UHC

Humana

Vertebral Axial Decompression

Aetna

Vertebral Body Tethering for Scoliosis

UHC

Musculoskelatal Therapy

Acute Inpatient Rehabilitation

Axial Spinal Decompression Therapy/
Mechanical Traction (Provided in a Clinic Setting

Chiropractic Services

Constraint-Induced Therapy

Fluidized Therapy (Fluidotherapy)

Mechanical Stretching Devices for Joint Stiffness & Contracture

Osteopathic Manipulative Treatment

Humana

Aetna

Aetna

FloridaBlue

UHC

Cigna

Occupational Therapy

Therapy & Rehabilitation Services

Physical Therapy

Physical Therapy
& Occupational Therapy

Range of Motion Testing

Strapping

Treatment of Autism Spectrum Disorders

Aetna

Cigna

Aetna

BCBSIL
BCBSMT
BCBSNM
BCBSOK
BCBSTX

Cigna

FloridaBlue

Medicare

Humana

Unna Boot

Electrical Stimulation for the Treatment of Arthritis

Suit Therapy

Aetna

Warming Therapy & Ultrasound Therapy for Wounds

Medicare

UHC

Musculoskeletal Imaging

CT

CT Bone Density Study

CT Cervical Spine

CT Lower Extremity (Ankle, Foot, Hip or Knee)

CT Lumbar Spine

CT Pelvis

Computed Tomography (CT) Spine (Cervical, Thoracic, Lumbar)

Magnetic Resonance Imaging (MRI) & Computed Tomography (CT) of the Spine

FloridaBlue

Aetna

Aetna

Whole Body Computed Tomography Scan as a Screening Test

CT Thoracic Spine

MRI

Magnetic Resonance Imaging (MRI) of the Ankle and Hindfoot

Humana

MRI) Lower Extremity

Aetna

FloridaBlue

MRI) Upper Extremity

FloridaBlue

Magnetic Resonance Spectroscopy

Nuclear Medicine

Nuclear Medicine Imaging

Anthem

PET/SPECT Scanning

Bone & Joint SPECT

Ultrasound

Spinal Ultrasonography

UHC

X-Ray/General

3D Interpretation
& Reporting of Imaging Studies

Computed Tomography (CT) Extremity (Upper and Lower)

FloridaBlue

MRI Bone Marrow

FloridaBlue

MRI Lumbar Spine

MRI Upper Extremity

Magnetic Resonance Spectroscopy for Discogenic Pain

Humana

SPECT Scan for Evaluation of Spondylolysis, Spondylolisthesis & Skeletal Disorders

Bone Mineral Density Studies

FEP

FloridaBlue

Humana

CT Upper Extremity

MRI Cervical Spine

Humana

MRI Pelvis

MRI Wrist

MRI Low Field

Single Photon Emission Computed Tomography (SPECT)

Aetna

MRI Elbow

Humana

MRI
Shoulder

Humana

Positional MRI

MRI Hip

Humana

MRI Spine

Aetna

FloridaBlue

Videofluoros-copy, Dynamic MRI for Musculoskel-etal Indications

Computerized Motion Diagnostic Imaging

Humana

Aetna

MRI Knee

Thermography

Humana

Magnetic Resonance Imaging (MRI) & Computed Tomography (CT) of the Spine

Aetna

Aetna

UHC

Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition

MRI Thoracic Spine

Diagnosis & Symptom Based Imaging

Advanced Imaging of the Ankle

Advanced Imaging of Chondral/
Osteochondral Lesions, Including Osteochondritis Dissecans & Fractures

Advanced Imaging of the Elbow

Advanced Imaging for Ganglion Cysts

Advanced Imaging of the Hand

Advanced Imaging of the Hip

Advanced Imaging of the Knee

Advanced Imaging of the Pelvis

Advanced Imaging of the Shoulder

Advanced Imaging of the Wrist

Avascular Necrosis (AVN)/ Osteonecrosis Imaging

Symptom Based Spine Imaging

Diagnosis Based Bone & Joint Pelvic Imaging

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