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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Indicates Non-covered Service

Gastrointestinal & General Surgery

Achalasia and Gastroesophageal Reflux Disease (GERD) Treatments
Ablative Therapy of Liver
Ablation of Hepatic Lesions
Anorectal Manometry & Electromyography (EMG) of the Urinary & Anal Sphincters
Appendectomy
Bariatric Surgery
Bariatric surgery for children and adolescents
Humana
FloridaBlue
Aetna
FloridaBlue
Maryland
Humana
Breast Biopsy Procedures
Breast ductal lavage and fiberoptic ductoscopy
Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy
Cecostomy for fecal incontinence
Cholecystectomy
Laparoscopic Cholecystectomy
Colectomy
Aetna
HPT
Aetna
Colon Capsule Endoscopy
Colorectal Cancer Screening
Continent Ileostomy and Urostomy
Core Needle Biopsy of the Breast
Destruction of Internal Hemorrhoids by Infrared Coagulation (IRC)
Colonoscopy
Anthem
Medicare
Humana
Medicare
UHC
Diagnostic Esophagogastro-duodenoscopy (EGD) or Esophagoscopy
Diagnostic Esophagogastro-duodenoscopy (EGD) or Esophagoscopy (age 59 years or younger) 
Double balloon enteroscopy
Barrett's Esophagus Treatment
Epigastric, Incisional, or Ventral Herniorrhaphy
Esophageal and Airway pH Monitoring
Fecal Incontinence Treatment
Medicare
FloridaBlue
Anthem
Aetna
Anthem
Aetna
Humana
UHC
Humana
FloridaBlue
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) and Laryngopharyngeal Endoscopic Esthesiometer (LPEER)
Gastric pacing, Enterra therapy
Gastric Electrical Stimulation
Gastrointestinal Manometry
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Gastro-photography (NCD 100.12)
High Resolution Anoscopy
Anthem
Aetna
FloridaBlue
Cigna
Aetna
Humana
Aetna
Incision and Drainage of abscess of skin, subcutaneous and accessory structures
Implantable Infusion Pump for Non-Musculoskeletal Conditions
Inguinal or Femoral Herniorrhaphy
Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers
Laparoscopic Hiatal Hernia Repair
Laparoscopic Sleeve Gastrectomy for Severe Obesity
Lipoma Excision
Humana
Medicare
Liver and Other Neoplasms - Treatment Approaches
Minimally Invasive Hemorrhoid Procedures
Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
Paraesophageal Hernia Repair
Aetna
Anthem
Peristeen anal irrigation system
Peroral Endoscopic Myotomy (POEM)
Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) Procedures
Select Minimally Invasive GERD Procedures (L35080)
Small Bowel Resection
Solesta Treatment for Fecal Incontinence
Surgical Management of Morbid Obesity
Cigna
Transanal Endoscopic Surgery (TES)
Transcatheter Arterial Chemoembol-ization as a Treatment for Primary or Metastatic Liver Malignancies
Transendoscopic Therapy for Gastroesoph-ageal Reflux Disease, Dysphagia and Gastroparesis
Transoral Incisionless Fundoplication (TIF)
Transrectal Ultrasound (TRUS)
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
Upper Gastrointestinal Endoscopy
Anthem
Aetna
IBC
Anthem
Upper Gastro-intestinal Endoscopy in Adults
Ventral Hernia Repair
Virtual Gastrointestinal Endoscopy
Capsule Endoscopy
Wireless Capsule Endoscopy
Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
Anthem
Aetna
Aetna
Humana
Anthem
Ablative Treatments for Malignant Breast Tumors
Adjunctive Techniques for Screening & Surveillance of Barrett’s Esophagus & Esophageal Dysplasia
Doppler-guided Transanal Hemorrhoidal Dearterialization
Ductal Lavage & Suction Collection Systems
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

Ingestible pH & Pressure Capsule

Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
Cigna
Anthem
FloridaBlue
FloridaBlue
FloridaBlue
FloridaBlue
Anthem
Minimally Invasive Procedures for the Treatment of Gastroesopha-geal Reflux Disease (GERD) & Dysphagia
FloridaBlue
Plugs for Anal Fistula Repair
FloridaBlue
Transanal Radiofrequency Treatment of Fecal Incontinence
Anthem

91110, 91111, 0355T, 45378, 45380, 43191, 43193, 43197, 43198, 43200, 43202, 43235, 43239, 43647, 43648, 43881, 43882, 64590, 43631, 43632, 43633, 43634, 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 0312T, 0313T, 0314T, 0315T, 0316T, 0317T,

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