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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Therapeutics

Indicates Non-covered Service

Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)
Chelation Therapy - Deferoxamine Mesylate (Desferal)
Chelation Therapy - Dimercaprol (BAL)
Low Density Lipoprotein (LDL) Apheresis
Outpatient Cardiac Rehabilitation
Peripheral Artery Disease of the Lower Extremities Angiography, Screening and Exercise Rehabilitation
FloridaBlue
Anthem
Humana
Allogeneic Hematopoietic Cell Transplantation
Allogeneic Pancreas Transplant
Autologous & Allogeneic Pancreatic Islet Cell Transplantation
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
Hematopoietic Stem Cell Transplantation for Genetic Diseases & Aplastic Anemias
Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
Hematopoietic Stem Cell Transplantation for Hodgkin Disease & non-Hodgkin Lymphoma
FloridaBlue
FloridaBlue
pedsolidtumor.jpg
Hematopoietic Stem Cell Transplantation for Multiple Myeloma & Other Plasma Cell Dyscrasias
Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
Hematopoietic Stem Cell Transplantation for Select Leukemias & Myelodysplastic Syndrome
Hematopoietic Stem Cell Transplant for Thalassemia Major & Sickle Cell Disease
Stem Cell Transplantation: Blood Cancers
Stem Cell Transplantation for Non-Cancer Disorders
Stem Cell Transplantation for Solid Tumors
Cigna
Cigna
Cigna
Aetna
Thymus Tissue Transplantation
Umbilical Cord Blood Progenitor Cell Collection, Storage & Transplantation
Anthem
Autologous Cellular Therapy for Certain Indications
Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation
UHC
Aetna
Assessing Your Weight
Healthy Weight & Finding a Balance
Losing Weight
Preventing Weight Gain
Chronic Kidney Disease
Chronic Kidney Disease Basic Education
Chronic Kidney Disease Prevention & Risk Management
Diabetes Care Schedule
Diabetes Education & Support
Diabetes & Mental Health
Preventing Diabetic Complications & Managing Sick Days
Education & Diabetic Management Program during Ramadan
Diabetic Pharmacological Management During Ramadan
Risk Stratification of Patients with T2 DM Who Wish to Fast During Ramadan
Structured Pre-Ramadan Education to Raise Awareness Risks of Diabetes & Fasting
Extended Release Opioids
Healthy Eating for a Healthy Weight
Healthy Weight
Healthy Weight & Finding a Balance
Hospitalization for the Initiation of a Ketogenic Diet
Cigna
Aetna
Physical Activity for a Healthy Weight
Tips for Parents-Ideas to Help Children Maintain a Healthy Weight
Healthy Weight & Eating Well with Diabetes
Living with Diabetes
Physical Activity for People with Diabetes
Chronic Pain Programs
Preparing for Natural Disasters for People with Diabetes
Aetna
Management of Your Blood Sugar
Managing Your Blood Sugar
Preventing Heart Disease
Preventing Heart Disease & Choosing Healthy Habits
Preventing Heart Disease & Knowing Your Risk for Heart Disease
Adult Preventive Health Guidelines
Quick Screen to Identify Excessive Drinking
Chronic Vertigo Treatment
Dysphagia/ Swallowing Diagnosis & Therapy
Treatment of Tinnitus
Ultrasonic Surgery for Meniere's Syndrome
Vestibular Rehabilitation
Voice Therapy
Humana
Aetna
FloridaBlue
FloridaBlue
Medicare
Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)
Chelation Therapy - Deferoxamine Mesylate (Desferal)
Chelation Therapy - Dimercaprol (BAL)
Fecal Bacteriotherapy
Fecal Microbiota Transplantation (FMT)
Gastric Pacing, Enterra Therapy
Humana
FloridaBlue
Levator Syndrome Treatment
Transanal Radiofrequency Therapy as a Treatment of Fecal Incontinence
FloridaBlue
Frequency of Hemodialysis 
Out-of-Network Outpatient Dialysis at
In-Network
Level of Benefits
Percutaneous Tibial Nerve Stimulation
Peritoneal Dialysis
Sacral Neuromodulation
Medicare
Apheresis
UHC
Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia & beta-Thalassemia
Chelation Therapy - Edetate Calcium Disodium (Calcium EDTA)
Chelation Therapy - Deferoxamine Mesylate (Desferal)
Chelation Therapy - Dimercaprol (BAL)
COVID-19 Convalescent Plasma
Low Density Lipoprotein (LDL) Apheresis
Plasmapheresis
FloridaBlue
Therapeutic Phlebotomy
Humana
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
Aetna
Cigna
Humana
FloridaBlue
Unna Boot
Electrical Stimulation for the Treatment of Arthritis
Suit Therapy
Aetna
Warming Therapy & Ultrasound Therapy for Wounds
UHC
elecwound.jpg
Electrical Stimulation Therapy and Devices in a Home Setting
Epilepsy Surgery
Ketogenic Diet for Treatment of Intractable Seizures
Monoclonal Antibody Therapies for Migraine Prevention
Neurological & Brain Injury Life Skills & Rehabilitation
Speech Language Pathology (SLP) Services: Communication Disorders
Subacute Inpatient Rehabilitation
Aetna
Cigna
Aetna
Spinal Cord Injury Inpatient Rehabilitation
TBI Inpatient Rehabilitation
Vagus Nerve Stimulation for Epilepsy
Aetna
Applied Behavioral Analysis (ABA)
Attention Deficit Hyperactivity Disorder Assessment & Treatment
Screening for Autism Spectrum Disorders & Rett Syndrome
Behavioral Health Coaching & Peer Support Services
Behavioral Health Observation Treatment
Biofeedback
Biofeedback for Chronic Pain
Humana
Cigna
Anthem
Aetna
Humana
Anthem
Cognitive Rehabilitation
Electroconvulsive Therapy (ECT)
Family Psychotherapy
Group Psychotherapy
Health & Behavior Assessment/ Intervention
Inpatient Adult Psychiatry Treatment
Days 1-6
Inpatient Adult Psychiatry Treatment Days 7-13
FloridaBlue
UHC
Aetna
Inpatient Subacute Care
Inpatient Treatment for Substance-Related & Addictive Disorder Treatment
Inpatient Withdrawal Management (Detoxification)
Intensive In-home Behavioral Health Services
Intensive Outpatient Program for Substance-Related & Addictive Disorder Treatment
Interactive Complexity Services
Low Intensity Residential with Clinical Services for Substance-Related & Addictive Disorder Treatment
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS161v10)
Methadone Treatment for Opiate Addiction
Anthem
Observation Status Adult Psychiatry
Outpatient (Office Based) Medication Assisted Treatment (MAT) of Opioid Use Disorder
Outpatient Treatment of Substance-Related & Addictive Disorder Treatment
Partial Hospitalization Program for Substance-Related & Addictive Disorder Treatment
Partial Hospital Program for Adult Psychiatry
Partial Hospitalization Program: Psychiatric Care
Phototherapy for Psychiatric Disorders
Aetna
Medicare
Psychiatric Diagnostic Evaluation
Psychiatric Inpatient Hospitalization
Adult Psychiatric Rehabilitation Program
Psychoanalysis
Psychological & Neuropsycho-logical Tests
Psychosocial Rehabilitation Services
Psychotherapy
Maryland
Psychotherapy for Crisis
Residential Treatment Center for Substance-Related & Addictive Disorder Treatment
Residential Treatment Center with 24-Hour Nursing for Substance-Related & Addictive Disorder Treatment
Residential Withdrawal Management (Detoxification)
Substance-Related & Addictive Disorder Treatment
Substance-Related & Addictive Disorder Treatment - Detoxification
Substance-Related & Addictive Disorder Treatment - Rehabilitation
Substance-Related Outpatient Withdrawal (Detoxification) with Extended On-Site Monitoring
Substance-Related Outpatient Withdrawal (Detoxification) without Extended On-Site Monitoring
Targeted Case Management
Transcranial Magnetic Stimulation (TMS)

64575, 64580, 64590, 94640, A4556, A4558, A4595, E0466, E0467, E0731, E0745, E0764, E0770, G0237, G0238, G0239, G0302, G0303, G0304, G0305, G0424, L8679, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8695, L8696, S9473

Accelerated Breast Irradiation & Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer
Brachytherapy-Oncologic Applications
Brachytherapy
FloridaBlue
Humana
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Chemotherapy Observation or Inpatient Hospitalization
Cranial
Stereotactic Radiosurgery (SRS)
& 
Cranial
Stereotactic Radiotherapy (SRT)
Disease Based Radiation Oncology
UHC
Cigna
Electric Tumor Treatment Field Therapy
Endobronchial Brachytherapy
Fractionation, Image-Guidance, & Special Services
High-Dose Rate Temporary Prostate Brachytherapy
Hyperthermia (deep, intracavitary, whole body) for Cancer Therapy
Hyperthermia (superficial external, interstitial) for Cancer Therapy
Hyperthermia Treatment for Cancer (Local, Regional & Whole Body)
FloridaBlue
UHC
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Image Guided Radiation Therapy
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Inpatient Admission for Radiation Therapy
Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
Intensity Modulated Radiation Therapy (IMRT)
Intensity-Modulated Radiation Therapy (IMRT): Abdomen & Pelvis
FloridaBlue
FloridaBlue
UHC
Cigna
Anthem
FloridaBlue
Humana
Intensity-Modulated Radiotherapy of the Breast & Lung
Intensity-Modulated Radiotherapy: Central Nervous System Tumors
Proton Beam Radiotherapy (CNS & axial skeleton)
FloridaBlue
Stereotactic Radiosurgery (SRS) & Stereotactic Body Radiation Therapy (SBRT)
FloridaBlue
Humana
UHC
Intensity-Modulated Radiotherapy: Cancer of the Head & Neck or Thyroid
Proton Beam Radiotherapy (Non CNS)
Stereotactic Radiosurgery (Intracranial)
FloridaBlue
Intensity-Modulated Radiotherapy of the Prostate
Proton & Neutron Beam Radiation Therapy
Humana
UHC
Tumor Treatment Fields (TTF) Therapy for Glioblastoma
FloridaBlue
Intraoperative Radiotherapy
Radiation Therapy for T1 Basal Cell & Squamous Cell Carcinomas of the Skin
Whole Brain Radiotherapy (WBRT)
Isolated Limb Perfusion-Infusion for Malignant Melanoma
Radioembolization for Primary & Metastatic Tumors of the Liver
Microwave Thermotherapy
Radiofrequency Tumor Ablation
Aetna
Oncologic Applications of Photodynamic Therapy
Aetna
Selective Internal Radiation Therapy (SIRT) for Primary & Secondary Hepatic Malignancy
FloridaBlue
Actinic Keratoses
Allergen Immunotherapy
Allergy Testing-
Eye
Allergy Testing: Patch testing
Allergy Testing: In vivo testing (skin tests)
Allergy Treatments
Electrical Stimulation (ES) & Electromagnetic Therapy for the Treatment of Wounds
Humana
Humana
EpiFix Wound Treatment
Lymphedema & Venous Stasis Ulcer Treatments
Complex Lymphedema Therapy (Complete Decongestive Therapy
Lymphedema - Diagnosis & Treatment
Phototherapy & Photochemotherapy (PUVA) for Skin Conditions
Targeted Phototherapy and Psoralen with Ultraviolet A for Vitiligo
Cigna
Humana
Aetna
Topical Photosensitizers used with PDT for Actinic Keratoses & Certain Skin Cancers
Treatment of Decubitus Ulcers
Wound Care
Allergen Immunotherapy
Ancillary Services for Pregnancy Complications
Aquatic Therapy
Art Therapy
Electrical Stimulation (ES) & Electromagnetic Therapy for the Treatment of Wounds
Humana
Brachytherapy
Low Level Laser Therapy (Cold Laser Therapy), High Power Laser Therapy
Donor Human Milk
Electric Stimulation for Pain, Swelling and Function in a Clinic Setting
Electrical Stimulators for Pain& Nausea/Vomiting
Electrical Stimulation for the Treatment of Pain & Muscle Rehabilitation
Equine-assisted Therapy for Behavioral Health
Humana
Anthem
Cigna
Humana
UHC
Home Phototherapy Devices for Neonatal Hyperbilirubinemia
Hydration Therapy
Hyperbaric & Topical Oxygen Therapies
Iontophoresis
Intestinal Rehabilitation Programs
Low Level Laser Therapy (Cold Laser Therapy), High Power Laser Therapy
Manipulative Therapy
Anthem
Aetna
Aetna
Cigna
FloridaBlue
Medicare
Humana
Humana
Medical Maggots
Medicinal Leech Therapy
Platelet-Derived Growth Factors for Wound Healing
Pritikin Program
Skilled Nursing Facility Services
Special Treatment Procedure & Special Physics Consult
Humana
FloridaBlue
Transcatheter Infusion Therapy

Indicates Non-covered Service

Adoptive Immunotherapy
Auditory & Sensory Integration Training Therapy (AIT)
Autologous Cell-Based Therapy for Cardiac and Peripheral Arterial Disease
Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP])
Biomagnetic Therapy
Bronchial Thermoplasty
Carotid Intima-Media Thickness Measurement
FloridaBlue
Cigna
Anthem
Cigna
FloridaBlue
Cigna
Cigna
FloridaBlue
Cigna
Headache & Occipital Neuralgia Treatment
Custodial & Non-Skilled Services
Cigna

Exhaled Nitric Oxide & Exhaled Breath Condensate in the Management of Respiratory

Disorders

Low Level Laser Therapy (Cold Laser Therapy), High Power Laser Therapy
High-Frequency Pulsed Electromagnetic Stimulation
Hippotherapy
Aetna
Neutron Beam Radiotherapy
Cigna
Anthem
Cigna
Aetna
Cigna

Rehabilitative Devices with Remote Monitoring

Ultrasound Therapy for Wound Healing
 Virtual Reality-Assisted Therapy Systems
Cigna
Humana
Anthem
Anthem
Anthem
Anthem
Anthem
parenteral-nutrition.jpg
Intradialytic Parenteral Nutrition
Anthem
nurse_at_computer.jpg
Computer Interface Rehabilitation Devices
Anthem
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