MSKaccess | ACGHolmes

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ACG

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

Automated Clinical Guidelines

Musculoskeletal ACCESS Model

Interventional Pain Management

Acupuncture

Aetna

Acupuncture forChronic Low Back Pain (cLBP)

Back Pain - Invasive Procedures

Botulinum Toxins

Continuous Peripheral Nerve Blocks (CPNB)

Dorsal Column Stimulation

Electric Stimulation for Pain, Swelling and Function in a Clinic Setting

Anthem

BlueMich

Cigna

Humana MA

Medicare

MA

Aetna

Cigna

HN

UHC MA

Transforaminal Epidural Injections

Selective Nerve Root Blocks
& Transforaminal Epidural Steroid Injections

Epidural Injections

Epidural & Selective Nerve RootBlock (SNRB)

Epidural Steroid Injections for Spinal Pain

Epidural Patching

Aetna

FloridaBlue

Cigna

Aetna

Epidural Steroid Injections for Pain Management excluding facet joint injections (L39015, L33906, L39036, L39240, L39242, L36920, L38994, L39054)

Medicare

UHC

Extended Release Opioids

Opioid Days' Supply Limitation

Radiofrequency Joint Ablation/
Denervation

Facet Joint Interventions

Facet Joint Interventions for Pain Management

Facet Joint Injections

Facet Joint Injections/Medial Branch Blocks

Humana

Cigna

FEP

Medicare

FloridaBlue

Cigna

Facet Joint Injections for Spinal Pain

Implantable Infusion Pumps for Pain or Spasticity

Injection of Morton's neuroma

Injections for Chronic Pain Conditions

Nerve Blockade for Treatment of Chronic Pain & Neuropathy

Nerve Block Injections

Ablative Treatment for Spinal Pain

UHC

Humana

Humana

Aetna

FloridaBlue

Aetna

UHC

Monitored Anesthesia Care (MAC)
Interventional Pain Management Procedures Adults

Moderate Sedation for Interventional Pain Management Procedures Adults

Neuroablative Techniques for Chronic Pain

Peripheral Nerve Blocks

Percutaneous Electrical Nerve Stimulation (PENS)

Percutaneous Vertebral Disc & Vertebral Endplate Procedures

Post-Herpetic Neuralgia Treatment

FloridaBlue

Cigna

Cigna

Humana

Medicare

FloridaBlue

Anthem

Aetna

Sacroiliac Joint Injections

FloridaBlue

Cigna

Spasticity Management

Spinal Cord Stimulation

Spinal Cord Stimulation for Chronic Pain

Spinal Cord & Dorsal Root Ganglion Stimulation

Tendon Sheath & Ligament Injections

Transcutaneous Electric Nerve Stimulation (TENS)

Trigger Point Injections

Aetna

Humana

Anthem

Aetna

Medicare

FloridaBlue

Cigna

FloridaBlue

FloridaBlue

FEP

FloridaBlue

UHC

Minimally Invasive Spine Surgery Procedures & Trigger Point Injections

Visco-supplementation

Visco-supplementation
for Osteoarthritis

Cigna

Cigna

Aetna

Humana

Cigna

Humana Medicaid

Medicare

UHC

Indicates Non-covered Service

Anesthetic & Antiemetic Infusion Pumps

Discogenic

Pain

Treatment

Epidural Adhesiolysis

Headache & Occipital Neuralgia Treatment

Headaches: Invasive Procedures

Intra-oral Appliances for Headaches & Trigeminal Neuralgia

Orthopedic Applications of Stem-Cell Therapy

Aetna

UHC

FloridaBlue

Cigna

FloridaBlue

Cigna

Aetna

Aetna

FloridaBlue

Cigna

Intravenous Lidocaine for the Management of Chronic Pain

Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation

Surface Scanning & Macro Electromy-ography

Ultrasound Guidance Trigger Point injections

Visco-

supplements

FloridaBlue

Cigna

Aetna

Cigna

FloridaBlue

Spine

Anterior Cervical Decompression with Fusion (ACDF) - Single Level (elective)

Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)

Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)

Anterior Vertebral Body Tethering

Back Pain - Invasive Procedures

Cervical Decompression with or without Fusion

Cervical Fusion

Aetna

Aetna

Cigna

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Cervical Fusion for Treatment of Axial Neck Pain (elective)

Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)

Cervical Disc Replacement

Aetna

Cervical laminectomy for herniated disc

Cervical Laminoplasty

Cervical Plexus Block

Cervical Posterior Decompression (elective)

Cigna

Anthem

Aetna

Cigna

FloridaBlue

Aetna

Humana

MA

Point32Health

Medicare

UHC

Cervical Posterior Decompression with Fusion - Multiple Levels (urgent/

emergent)

Cervical Posterior Decompression with Fusion-Single Level (elective)

Referral Indications- Cervical Spine

Cervical Spine Procedures

Coccygectomy & Treatments for Coccydynia

Discography- Lumbar

Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

FloridaBlue

Anthem

Aetna

Cigna

Humana

FEP

Sacral Nerve Stimulation

Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406)

Sacroiliac Joint Fusion

Sacroiliac Joint Procedures

Scoliosis and Spinal Deformity

Scoliosis Surgery (Vertebral Body Tethering)

Single Level Lumbar Fusion with or without decompression (elective)

FloridaBlue

Medicare

FloridaBlue

Anthem

Cigna

Medicare

Anthem

Lumbar Discectomy/ Microdiscectomy (elective)

Lumbar Spinal Fusion

Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)

Referral Indications Lumbar Spine

Lumbar Spinal Procedures

Lumbar Total Disc Arthroplasty (TDA)

Anthem

Medicare

Anthem

Anthem

FloridaBlue

Anthem

Medicare

UHC

Multi-level Lumbar Fusions with or without decompression (elective)

Pedicle screws for spinal fixation and intervertebral body fusion devices

Percutaneous Vertebral Augmentation

Percutaneous Vertebral Disc and Vertebral Endplate Procedures

Recombinant Human Bone Morphogenetic Protein (BMP)

Repeat Lumbar Spine Fusion Operations (elective)

Anthem

FloridaBlue

Humana

Anthem

FloridaBlue

Growing Rods for Spinal Surgery

Idiopathic Scoliosis Treatment

Interspinous Process Decompression

Intervertebral Disc Prostheses

Laminectomy, Laminotomy, Facetectomy, & Foraminotomy (elective)

Laminectomy and Fusion

Lumbar Laminectomy

Aetna

Medicare

Aetna

Anthem

Aetna

Anthem

FEP

Cigna

Humana

Spinal Decompression Surgery

Surgery for Spinal Deformity

Surgical Treatment of Chest Wall Deformities

Spinal Fusion Surgery- All Levels

Thoracic laminectomy and/or thoracic diskectomy and fusion

Thoracic laminectomy and/or thoracic diskectomy and fusion

Thoracoscopic Sympathectomy

Humana

FloridaBlue

Cigna

Aetna

Humana

UHC

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

Facet Arthroplasty

Humana

Humana

UHC

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

Skeletal Analysis Systems

Traction Devices – Cervical & Lumbar

Aetna

FEP Blue

Aetna

Aetna

Cigna

FloridaBlue

Cigna

FloridaBlue

UHC

Humana

Vertebral Axial Decompression

Aetna

Vertebral Body Tethering for Scoliosis

UHC

Musculoskelatal Therapy

Acute Inpatient Rehabilitation

Axial Spinal Decompression Therapy/
Mechanical Traction (Provided in a Clinic Setting

Chiropractic Services

Constraint-Induced Therapy

Fluidized Therapy (Fluidotherapy)

Mechanical Stretching Devices for Joint Stiffness & Contracture

Osteopathic Manipulative Treatment

Humana

Aetna

Aetna

UHC

Cigna

FloridaBlue

Occupational Therapy

Therapy & Rehabilitation Services

Physical Therapy

Physical Therapy
& Occupational Therapy

Range of Motion Testing

Strapping

Treatment of Autism Spectrum Disorders

Aetna

Cigna

Aetna

BCBSIL
BCBSMT
BCBSNM
BCBSOK
BCBSTX

Cigna

FloridaBlue

Medicare

Humana

Unna Boot

Electrical Stimulation for the Treatment of Arthritis

Suit Therapy

Aetna

Warming Therapy & Ultrasound Therapy for Wounds

Medicare

UHC

Musculoskeletal Imaging

CT

CT Bone Density Study

CT Cervical Spine

CT Lower Extremity (Ankle, Foot, Hip or Knee)

CT Lumbar Spine

CT Pelvis

Computed Tomography (CT) Spine (Cervical, Thoracic, Lumbar)

Magnetic Resonance Imaging (MRI) & Computed Tomography (CT) of the Spine

FloridaBlue

Aetna

Aetna

Whole Body Computed Tomography Scan as a Screening Test

CT Thoracic Spine

MRI

Magnetic Resonance Imaging (MRI) of the Ankle and Hindfoot

Humana

MRI) Lower Extremity

Aetna

FloridaBlue

MRI) Upper Extremity

FloridaBlue

Magnetic Resonance Spectroscopy

Nuclear Medicine

Nuclear Medicine Imaging

Anthem

PET/SPECT Scanning

Bone & Joint SPECT

Ultrasound

Spinal Ultrasonography

UHC

X-Ray/General

3D Interpretation
& Reporting of Imaging Studies

Diagnosis & Symptom Based Imaging

Advanced Imaging of the Ankle

Advanced Imaging of the Pelvis

Computed Tomography (CT) Extremity (Upper and Lower)

FloridaBlue

MRI Bone Marrow

FloridaBlue

MRI Lumbar Spine

MRI Upper Extremity

Magnetic Resonance Spectroscopy for Discogenic Pain

Humana

SPECT Scan for Evaluation of Spondylolysis, Spondylolisthesis & Skeletal Disorders

Bone Mineral Density Studies

FEP

FloridaBlue

Humana

Advanced Imaging of Chondral/
Osteochondral Lesions, Including Osteochondritis Dissecans & Fractures

Advanced Imaging of the Shoulder

CT Upper Extremity

MRI Cervical Spine

Humana

MRI Pelvis

MRI Wrist

MRI Low Field

Single Photon Emission Computed Tomography (SPECT)

Aetna

Advanced Imaging of the Elbow

Advanced Imaging of the Wrist

MRI Elbow

Humana

MRI
Shoulder

Humana

Positional MRI

Advanced Imaging for Ganglion Cysts

Avascular Necrosis (AVN)/ Osteonecrosis Imaging

MRI Hip

Humana

MRI Spine

Aetna

FloridaBlue

Videofluoros-copy, Dynamic MRI for Musculoskel-etal Indications

Computerized Motion Diagnostic Imaging

Humana

Aetna

Advanced Imaging of the Hand

Symptom Based Spine Imaging

MRI Knee

Thermography

Humana

Magnetic Resonance Imaging (MRI) & Computed Tomography (CT) of the Spine

Aetna

Aetna

UHC

Advanced Imaging of the Hip

Diagnosis Based Bone & Joint Pelvic Imaging

MRI Thoracic Spine

Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition

Advanced Imaging of the Knee

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