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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Neurologic & Neurosurgery

Indicates Non-covered Service
Anterior Cervical Decompression with Fusion (ACDF) - Single Level (elective)
Bone Graft Substitutes
Bone Growth Stimulators
Brachial Plexus Surgery
Cervical Disc Replacement
Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)
Artificial Intervertebral Disc Replacement
Cigna
Humana
Humana
Cigna
Humana
Aetna
Aetna
Humana
Cigna
FloridaBlue
Anthem
Medicare
UHC
Cervical Fusion for Treatment of Axial Neck Pain (elective)
Cervical Posterior Decompression with Fusion-Single Level (elective)
Cervical spinal fusion
Cervical Posterior Decompression with Fusion - Multiple Levels (urgent/ emergent)
Cervical Posterior Decompression (elective)
Cervical laminectomy other than for herniated disc
Cervical Spine Indications for Referrals
Cervical Spine Procedures
Chiari Malformation Decompression Surgery
Cluster and Migraine Headaches Treatment
Cervical Laminoplasty
Cervical laminectomy (and/or an anterior cervical diskectomy and fusion) for herniated disc
Aetna
Complex regional pain syndrome
Discography
Selective dorsal rhizotomy for cerebral palsy
Endoscopic and Percutaneous Lysis of Epidural Adhesions
Epidural Lysis of Adhesions
Deep Brain Stimulation for Essential Tremor and Parkinson's Disease
Deep Brain Stimulation and Responsive Neurostimulation
Aetna
Cigna
FloridaBlue
Humana
Medicare
Cigna
Humana
Anthem
Humana
Electrical Bone Growth Stimulation: Noninvasive

Hydrodissection

-Humana-

Non-covered

Implantable Infusion Pump for Pain and Spasticity
Growing rods for spinal surgery

Facet

Arthroplasty

-Humana-

Non-covered

Interspinous & Interlaminar Stabilization/Distraction (Spacers) & Fixation (Fusion) Devices

Laminectomy, Laminotomy, Facetectomy, and Foraminotomy (elective)

Laser Interstitial Thermal Therapy
Laser Interstitial Thermal Therapy
Intraoperative Neurophysiology Monitoring

Interspinous Process Decompression

Lumbar Discectomy/Microdisc-ectomy (elective)

Lumbar Spine Surgery

Lumbar Total Disc Arthroplasty (TDA)
Minimally Invasive Ablative Procedures for Epilepsy
Multi-level Lumbar Fusions with or without decompression (elective)
Lumbar Spine Indications for Referral

Lumbar Spinal Fusion

Cigna
Humana
Humana
Cigna
FloridaBlue
Humana
Aetna
Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)

Surgical Treatment of Occipital Neuralgia & Headache

Optic Nerve Decompression Surgery
Osteopathic Manipulative Treatment
Occipital Nerve Stimulation

Occipital Neuralgia and Headache Treatment

UHC
FloridaBlue
FloridaBlue
Pedicle screws for spinal fixation and intervertebral body fusion devices

Peripheral Nerve Stimulation & Peripheral Nerve Field Stimulation

 Recombinant Bone Morphogenetic Protein (BMP)
Regional Sympathetic Blocks
Repeat Lumbar Spine Fusion Operations (elective)
Percutaneous Vertebral Disc and Vertebral Endplate Procedures

Vertebroplasty, Vertebral Augmentation; Percutaneous

Humana
Anthem
Cigna
FloridaBlue
Cigna
Scoliosis and Spinal Deformity

Thoracic laminectomy and/or thoracic diskectomy and fusion

Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406)
Selective Peripheral Denervation (Bertrand Procedure)
SI Joint Fusion
Spinal Decompression Surgery

Spasticity Management

Single Level Lumbar Fusion with or without decompression (elective)

Stereotactic Cingulotomy

Thalamotomy
Treatment of Trigeminal Neuralgia
Spinal Fusion Surgery

Spinal Decompression Surgery

Humana
Humana
FloridaBlue
Medicare
Medicare
non-Medicare
Humana
Aetna
Aetna
FloridaBlue
Point32Health

20974, 20975, 20979, E0747, E0748, E0749, E0760, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 64999, C1772, C1891, C2626, E0782, E0783, E0785, E0786,

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