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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Orthopaedic-All Other

Indicates Non-covered Service

Ablative Therapy of Bone
Anthem
Humana
Arthrocentesis
Bone Graft Substitutes and Bone Morphogenetic Proteins
Anthem
Humana
Noninvasive Electrical Bone Growth Stimulation
Humana
Complex Regional Pain Syndrome (RSD)
Cigna
Debridement Services
Debridement Services of bone, muscle, fascia, and subcutaneous tissue
Debridement Services of Extensive Eczematous or Infected Skin
Excision of malignant skin lesions: Trunk, arms, or legs
Internal Rib Fixation System
Implantable Infusion Pump for Pain and Spasticity
Humana
Implantable Intrathecal Drug Delivery Systems
Cigna
Incision and Drainage of abscess of skin, subcutaneous and accessory structures
Intraoperative Neurological Monitoring
Invasive Electrical Bone Growth Stimulator (EBGS)
FloridaBlue
Manipulation Under Anesthesia
UHC
Bio-Surgery Medicinal Leech Therapy and Medical Maggots
Aetna
Osteopathic Manipulative Treatment
Treatment of leg length discrepancy
Ultrasound Ablation for Oncologic Indications High Intensity Focused Ultrasound (HIFU)
Anthem

Indicates Non-covered Service

Athletic Pubalgia Surgery
Humana
Cigna
Autologous Cellular Implant Derived from Adipose Tissue
Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP])
FloridaBlue
Computer-Assisted Navigation for Orthopedic Procedures
UHC
Cigna

Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions &

Soft Tissue Wounds

Humana
UHC
Humana

Ablation Techniques & Extracorporeal Shock Wave Therapy for Musculoskeletal Indications & Soft Tissue Wounds

Cigna
Cartilage Regeneration Membrane
 Electrothermal Intradiscal Therapies
Humana
 Electrothermal Arthroscopy
Aetna
Healing Response Technique
Cigna
In-Office Diagnostic Arthroscopy
Cigna
Irreversible Electroporation (NanoKnife)
Humana
FloridaBlue
Surgical Treatment of Occipital Neuralgia & Headache
FloridaBlue
Orthopedic Applications of Stem-Cell Therapy
FloridaBlue
Cigna
Prolotherapy for Musculo-skeletal Indications
Humana
Cigna
UHC
Subchon-droplasty
Cigna
Thermal Shrinkage
Cigna
Xenograft Implantation into the Articular Surface
Cigna
Inpatient Setting for Elective Total Joint Arthroplasty
HPT

20974, 20975, 20979, E0747, E0748, E0749, E0760

Amputation of Digit or Extremity
UHC
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