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ACG

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

Automated Clinical Guidelines

Spine

Indicates Non-covered Service

Cervical Disc Replacement
Laminectomy and Fusion
Aetna
Humana

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
Humana
UHC
FloridaBlue
Humana
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
Traction Devices – Cervical & Lumbar
Aetna
Skeletal Analysis Systems
FEP Blue
Aetna
Aetna
Cigna
FloridaBlue
Cigna
FloridaBlue
UHC
Humana
Vertebral Axial Decompression
Aetna
Vertebral Body Tethering for Scoliosis
UHC

0200T, 0201T, 0202T, 0219T, 0220T, 0221T, 0222T, 0274T, 0275T, 20930, 20931, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22859, 22867, 22868, 22869, 22870, 22899, 27279, 27280, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63275, 63277, 63280, 63282, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63275, 63277, 63280, 63282, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 63650, 63655, 63663, 63664, 63685, 63688, 64999, C1816, C1820, C1822, L8679, L8680, L8682, L8685, L8686, L8687, L8688

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