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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

OB & Gyn

Indicates Non-covered Service
Abortion
Assistive Reproductive Technology and Infertility
Cervical Cancer Screening and Diagnosis
Chlamydia Trachomatis Screening and Diagnosis
Cryopreservation of Oocytes or Ovarian Tissue
Amniocentesis for diagnosis of fetal chromosomal abnormalities
Minimally Invasive Treatment of Abnormal Uterine Bleeding (AUB)
Cigna
Anthem
FloridaBlue
Aetna
Aetna
Diagnostic Hysteroscopy for Infertility
Endometrial Cancer Screening and Diagnosis
Essure Removal
Fertility Preservation
Fetal Surgery in Utero for Prenatally Diagnosed Malformations
Diagnostic Hysteroscopy for Infertility
Endometrial ablation
Anthem
Cigna
Aetna
Aetna
Gender Reassignment Surgery
Infertility Evaluation and Treatment
Diagnosis and Treatment of Organ Prolapse
Fetal surgery in utero
Hysterectomy
Incision and Drainage of abscess of skin, subcutaneous and accessory structures
Occlusion of Uterine Arteries Using Transcatheter Embolization
Pelvic Denervation Procedures
Percutaneous Tibial Nerve Stimulation
Prophylactic bilateral oophorectomy
Prophylactic Mastectomy
Organ Prolapse Treatment
Pelvic Congestion Syndrome Treatment
FloridaBlue
Cigna
FloridaBlue
FloridaBlue
Recurrent Pregnancy Loss Evaluation and Treatment
Transrectal Ultrasound (TRUS)
Transvaginal Ultrasonography (TV-US)
Tubal Sterilization
Fibroid Treatment
Transabdominal Cerclage
Transcervical balloon tuboplasty
Uterine fibroid surgical treatments
Uterine artery embolization
Vulvodynia & Vulvar Vestibulitis Treatments
Aetna
Aetna
FloridaBlue
Breast Ductoscopy
Selected Tests for the Evaluation & Management of Infertility

Tests for the Evaluation of Preterm Labor

& Premature Rupture of Membranes

Tumor In Vitro Chemosensitivity & Chemoresistance Assays
Vein Embolization  Treatment for Pelvic Congestion Syndrome & Varicocele
Cervical Cancer Screening Visualization Technologies
Mammary Ductoscopy, Aspiration & Lavage
Indicates Non-covered Service
FloridaBlue
Cigna
Cigna
Anthem
Cigna
Antepartum Fetal Surveillance
Aetna
Maternal Fetal Medicine & High Risk Obstetrics
UHC
Ultrasound in Pregnancy
Amnioinfusion
Aetna
Preimplantation Embryo Biopsy
Anthem
Home Uterine Activity Monitoring (HUAM)

52402, 54800, 54840, 54900, 54901, 55200, 55300, 55400, 55550, 55870, 58321, 58322, 58323, 58340, 58345, 58350, 58555, 58559, 58560, 58660, 58662, 58672, 58673, 58740, 58750, 58752, 58760, 58770, 58900, 58970, 58974, 58976, 74440, 74740, 74742, 76831, 76856, 76857, 76948, 80414, 80415, 80426, 82757, 84830, 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89300, 89310, 89320, 89321, 89322, 89325, 89329,89330, 89331, 89335, 89337, 89342, 89343, 89344, 89346, 89352, 89353, 89354, 89356, 89398, G0027, Q0115, S3655, S4011, S4013, S4014, S4015, S4016, S4017, S4018, S4020, S4021, S4022, S4023, S4025, S4026, S4027, S4028, S4030, S4031, S4035, S4037, S4040, S4042,

Prophylactic Oophorectomy or Salpingooophorectomy with or without Hysterectomy
Cigna
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