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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Gastrointestinal & General Surgery

Indicates Non-covered Service
Achalasia and Gastroesophageal Reflux Disease (GERD) Treatments
Appendectomy
Bariatric Surgery
Bariatric surgery for children and adolescents
Breast Biopsy Procedures
Ablative Therapy of Liver
Aetna
Ablation of Hepatic Lesions
Humana
FloridaBlue
FloridaBlue
Humana
Maryland
Aetna
Breast ductal lavage and fiberoptic ductoscopy
Cholecystectomy
Colectomy
Colon Capsule Endoscopy
Continent Ileostomy and Urostomy
Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy
Cecostomy for fecal incontinence
Aetna
Medicare
Core Needle Biopsy of the Breast
Diagnostic Esophagogastro-duodenoscopy (EGD) or Esophagoscopy
Diagnostic Esophagogastro-duodenoscopy (EGD) or Esophagoscopy (age 59 years or younger) 
Colonoscopy
Destruction of Internal Hemorrhoids by Infrared Coagulation (IRC)
Anthem
Medicare
UHC
UHC
Medicare
Humana
Double balloon enteroscopy
Esophageal and Airway pH Monitoring
Fecal Incontinence Treatment
Epigastric, Incisional, or Ventral Herniorrhaphy
Humana
Barrett's Esophagus Treatment
Aetna
Anthem
FloridaBlue
Aetna
FloridaBlue
Anthem
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) and Laryngopharyngeal Endoscopic Esthesiometer (LPEER)
Gastrointestinal Manometry
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Gastro-photography (NCD 100.12)
High Resolution Anoscopy
Gastric pacing, Enterra therapy
Gastric Electrical Stimulation
Aetna
Anthem
Cigna
FloridaBlue
Aetna
Aetna
Humana
Incision and Drainage of abscess of skin, subcutaneous and accessory structures
Laparoscopic Hiatal Hernia Repair
Laparoscopic Sleeve Gastrectomy for Severe Obesity
Lipoma Excision
Inguinal or Femoral Herniorrhaphy
Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers
Humana
Medicare
Liver and Other Neoplasms - Treatment Approaches
Paraesophageal Hernia Repair
Minimally Invasive Hemorrhoid Procedures
Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
Aetna
Anthem
Peristeen anal irrigation system
Select Minimally Invasive GERD Procedures (L35080)
Small Bowel Resection
Solesta Treatment for Fecal Incontinence
Surgical Management of Morbid Obesity
Peroral Endoscopic Myotomy (POEM)
Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) Procedures
Cigna
Transanal Endoscopic Surgery (TES)
Transoral Incisionless Fundoplication (TIF)
Transrectal Ultrasound (TRUS)
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
Upper Gastrointestinal Endoscopy
Transcatheter Arterial Chemoembol-ization as a Treatment for Primary or Metastatic Liver Malignancies
Transendoscopic Therapy for Gastroesoph-ageal Reflux Disease, Dysphagia and Gastroparesis
Anthem
Aetna
Anthem
Upper Gastro-intestinal Endoscopy in Adults
Capsule Endoscopy
Wireless Capsule Endoscopy
Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
Ventral Hernia Repair
Virtual Gastrointestinal Endoscopy
Anthem
Aetna
Aetna
Humana
Anthem
Ablative Treatments for Malignant Breast Tumors
Ductal Lavage & Suction Collection Systems
Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
Minimally Invasive Procedures for the Treatment of Gastroesopha-geal Reflux Disease (GERD) & Dysphagia
Plugs for Anal Fistula Repair
Adjunctive Techniques for Screening & Surveillance of Barrett’s Esophagus & Esophageal Dysplasia
Doppler-guided Transanal Hemorrhoidal Dearterialization
Anthem
Cigna
FloridaBlue
FloridaBlue
Anthem
FloridaBlue
FloridaBlue
Transanal Radiofrequency Treatment of Fecal Incontinence
Anthem
Implantable Infusion Pump for Non-Musculoskeletal Conditions
Laparoscopic Cholecystectomy
HPT
Anorectal Manometry & Electromyography (EMG) of the Urinary & Anal Sphincters
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

Ingestible pH & Pressure Capsule

Colorectal Cancer Screening
FloridaBlue
Humana
FloridaBlue

91110, 91111, 0355T, 45378, 45380, 43191, 43193, 43197, 43198, 43200, 43202, 43235, 43239, 43647, 43648, 43881, 43882, 64590, 43631, 43632, 43633, 43634, 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 0312T, 0313T, 0314T, 0315T, 0316T, 0317T,

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