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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Knee

Indicates Non-covered Service

Allograft Transplantation of the Knee
Aetna
Anthem
Humana
Arthroscopic anterior cruciate ligament surgery in the skeletally immature
Articular Cartilage Restoration  Repair of the Knee
Functional Status Assessment for Total Knee Replacement (CMS66v10)
High Tibial Osteotomy
UHC
Knee Arthroscopy
UHC
Cigna
FloridaBlue
Humana
Knee Arthroscopy and Open Procedures
Anthem
Autologous Chondrocyte Implantation (ACI)
FloridaBlue
Knee injury and Osteoarthritis Outcome Score (KOOS)
Knee Arthroplasty
UHC
Cigna
FloridaBlue
Humana
Anthem
commercial
Medicare
Osteoarthritis of the Knee: Selected Treatments
Aetna
Treatment of Osteochondral Defects
Anthem
Humana
Outpatient Total Knee and Total Hip Arthroplasty
Patellofemoral or Unicondylar Knee Replacement
UHC

Indicates Non-covered Service

Autologous Chondrocyte Implantation
Cigna
FloridaBlue
Computer-Assisted Navigation for Orthopedic Procedures
Continuous Passive Motion (CPM) & Mechanical Stretching Devices
Cigna
Humana
FloridaBlue
Cooling & Heating Devices Used in the Outpatient Settings
Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
Knee Ligament Arthrometer Testing
Aetna
Menaflex Device
Aetna
FloridaBlue
Orthopedic Applications of Stem-Cell Therapy
Osteochondral Allograft Transplantatio
Cigna
Osteochondral Autograft Transplantation
Cigna
FloridaBlue

Unicondylar Interpositional Spacer

Devices

Humana
UHC
FloridaBlue

Visco-

supplements

Knee Surgery
Point32Health
Aetna
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