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ACG

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

Automated Clinical Guidelines

Spine

Indicates Non-covered Service

Cervical Disc Replacement
Aetna
Laminectomy and Fusion
Humana

Indicates Non-covered Service

Automated Percutaneous Discectomy, Laser Discectomy, Percutaneous Endoscopic Discectomy, & DISC Nucleoplasty
FloridaBlue
Axial LIF
Aetna
Discography
UHC
Dynamic Spinal Stabilization Devices
Humana
Epidural Lysis of Adhesions
Humana
UHC
Epiduroscopy
UHC
FloridaBlue
Humana
Facet Arthroplasty
Interspinous & Interlaminar Stabilization/Distraction (Spacers) & Fixation (Fusion) Devices
FloridaBlue
Cigna
Humana
Intradiscal Procedures
Aetna
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofre-quency Annuloplasty, & Biacuplasty
FloridaBlue
Pulsed Radiofrequency
Aetna
Skeletal Analysis Systems
Aetna
Traction Devices – Cervical & Lumbar
Cigna
Aetna
UHC
Vertebral Axial Decompression
Aetna
Vertebral Body Tethering for Scoliosis
UHC
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