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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)
Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)
Artificial Intervertebral Disc Replacement
Bone Graft Substitutes
Bone Growth Stimulators
Brachial Plexus Surgery
Cervical Disc Replacement
Cigna
Humana
Cigna
Humana
Aetna
Aetna
Point32Health
Anthem
Humana
FloridaBlue
Cigna
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Medicare
Humana
UHC
Cervical Fusion for Treatment of Axial Neck Pain (elective)
Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)
Cervical Posterior Decompression (elective)
Cervical Posterior Decompression with Fusion - Multiple Levels (urgent/ emergent)
Cervical Posterior Decompression with Fusion-Single Level (elective)
Cervical spinal fusion
Cervical laminectomy other than for herniated disc
Cervical laminectomy (and/or an anterior cervical diskectomy and fusion) for herniated disc
Cervical Laminoplasty
Cervical Spine Indications for Referrals
Cervical Spine Procedures
Chiari Malformation Decompression Surgery
Cluster and Migraine Headaches Treatment
FloridaBlue
Aetna
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Complex regional pain syndrome
Deep Brain Stimulation and Responsive Neurostimulation
Deep Brain Stimulation for Essential Tremor and Parkinson's Disease
Deep Brain Stimulation for Essential Tremor & Parkinson's Disease (NCD 160.24)
Discography
Cigna
Selective dorsal rhizotomy for cerebral palsy
Electrical Bone Growth Stimulation: Noninvasive
Aetna
Humana
FloridaBlue
Cigna
Medicare
Humana
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Electrical Nerve Stimulators (NCD 160.7)
Endoscopic and Percutaneous Lysis of Epidural Adhesions
Epidural Lysis of Adhesions

Facet

Arthroplasty

-Humana-

Non-covered

Growing rods for spinal surgery

Hydrodissection

-Humana-

Non-covered

Implantable Infusion Pump for Pain and Spasticity
Anthem
Humana
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Induced Lesions of Nerve Tracts (NCD 160.1)
Interspinous & Interlaminar Stabilization/Distraction (Spacers) & Fixation (Fusion) Devices

Interspinous Process Decompression

Intraoperative Neurophysiology Monitoring

Laminectomy, Laminotomy, Facetectomy, and Foraminotomy (elective)

Laser Interstitial Thermal Therapy
Laser Interstitial Thermal Therapy
Humana
Cigna
Cigna
FloridaBlue
Humana
Humana
Lumbar Discectomy/Microdisc-ectomy (elective)

Lumbar Spinal Fusion

Lumbar Spine Indications for Referral

Lumbar Spine Surgery

Lumbar Total Disc Arthroplasty (TDA)
Minimally Invasive Ablative Procedures for Epilepsy
Multi-level Lumbar Fusions with or without decompression (elective)
Aetna
Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)

Occipital Neuralgia and Headache Treatment

Occipital Nerve Stimulation

Surgical Treatment of Occipital Neuralgia & Headache

Optic Nerve Decompression Surgery
Osteopathic Manipulative Treatment
FloridaBlue
UHC
FloridaBlue
Pedicle screws for spinal fixation and intervertebral body fusion devices

Vertebroplasty, Vertebral Augmentation; Percutaneous

Percutaneous Vertebral Disc and Vertebral Endplate Procedures

Peripheral Nerve Stimulation & Peripheral Nerve Field Stimulation

 Recombinant Bone Morphogenetic Protein (BMP)
Regional Sympathetic Blocks
Repeat Lumbar Spine Fusion Operations (elective)
Humana
Anthem
Cigna
Cigna
FloridaBlue
Scoliosis and Spinal Deformity

Spasticity Management

Spinal Decompression Surgery

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
Humana
Medicare
non-Medicare
FloridaBlue
Medicare
Single Level Lumbar Fusion with or without decompression (elective)

Spinal Decompression Surgery

Spinal Fusion Surgery

Stereotactic Cingulotomy

Thalamotomy
Treatment of Trigeminal Neuralgia
Humana
Humana
Aetna
Aetna
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Vagus Nerve Stimulation (NCD 160.18)

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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