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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Cognitive WISeR Model

Indicates Non-covered Service

Beginning January 1, 2026, the prior authorization process under this model will be implemented in the selected states on the following items and services with affiliated NCDs or LCDs
 
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Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L39764)
Arthroscopic Lavage & Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)
Deep Brain Stimulation for Essential Tremor & Parkinson's Disease (NCD 160.24)
Diagnosis & Treatment of Impotence (NCD 230.4)
Electrical Nerve Stimulators (NCD 160.7)
Epidural Steroid Injections for Pain Management excluding facet joint injections (L39015, L33906, L39036, L39240, L39242, L36920, L38994, L39054)
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Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38276, L38307, L38398, L38387, L38310, L38312, L38385, L38528)
Incontinence Control Devices
(NCD 230.10)
Induced Lesions of Nerve Tracts (NCD 160.1)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L33569, L34106, L34228, L38201, L34976, L35130, L38737, L38213)
Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
(NCD 150.13)
Phrenic Nerve Stimulator
(NCD 160.19)
Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
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Vagus Nerve Stimulation (NCD 160.18)
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Wound Application of Cellular /Tissue Based Products, Lower Extremities (L36690)
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