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Automated Clinical Guidelines


Indicates Non-covered Service

Autologous Hematopoietic Cell Transplantation
Automated Percutaneous Discectomy, Laser Discectomy, Percutaneous Endoscopic Discectomy, & DISC Nucleoplasty
Balloon Ostial Dilation (Balloon Sinuplasty) & Implantable Devices
Bronchial Thermoplasty
Breast Ductoscopy
Cryoablation of Liver Tumors
Complications of Pregnancy
Computer-Assisted Navigation for Orthopedic Procedures
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Endothelial Keratoplasty & Corneal Collagen Cross-Linking
Ductal Lavage & Suction Collection Systems
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis & Aneurysms) & Extracranial Vertebral Artery Disease
Facet Arthroplasty
High Resolution Anoscopy
Implantable Cardioverter Defibrillators, Cardiac Contractility Modulation (CCM) Therapy
In Utero (Intrauterine) Fetal Surgery
Interstitial Laser Therapy for Breast Tumors
Irreversible Electroporation (IRE)
Interspinous & Interlaminar Stabilization/ Distraction (Spacers) & Fixation (Fusion) Devices
Isolated Small Bowel Transplant
Kidney Transplant
Laser Vitreolysis
Lysis of Epidural Adhesions
Microwave Tumor Ablation Other Than Liver Tumors
Ooccipital Nerve Stimulation
Partial Left Ventriculectomy & Surgical Ventricular Restoration
Photocoagulation of Macular Drusen
Platelet-Derived Growth Factors & Platelet-Rich Plasma
Plugs for Fistula Repair
Radiofrequency & Microwave Ablation of Liver Tumors
Prophylactic Mastectomy
Radiofrequency Ablation of Solid Tumors Other Than Liver Tumors
Reconstructive Surgery/ Cosmetic Surgery
Transmyocardial Revascularization (TMR)
Transurethral Waterjet Ablation of the Prostate
Unicondylar Interpositional Spacer Devices
Viscocanalostomy & Canaloplasty
Vagus Nerve Stimulation
Subtalar Arthroereisis
Surgical Treatments for Lymphedema & Lipedema
Surgical Treatment of Occipital Neuralgia & Headache
Temporary Prostatic Urethral Stents (Including Implantable Nitinol Devices) & Prostatic Urethral Lift
Thumb Basal Joint Arthroscopy
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