Medical Policy Reference Manual

CareFirst BlueCross BlueShield And D.C. Children's Hospital Agree On New Contract

Medical Policy Reference Manual

00. Introduction

01. Durable Medical Equipment

02. Medicine

03. Mental Health

04. OB/GYN/Reproduction

05. Prescription Drug

06. Radiology/Imaging

07. Surgery

7.01.003 Bone-Anchored Hearing Aids

7.01.005 Cochlear Implantation

7.01.006 Dynamic Cardiomyoplasty

7.01.007 Electrical Bone Growth Stimulation

7.01.008 Vascular Angioscopy

7.01.010 Fetal Mesencephalic Transplantation for the Treatment of Parkinson’s Disease

7.01.011 Bone Lengthening for Angular Deformities and Limb Length Discrepancies of Long Bones

7.01.013 Keratoprosthesis

7.01.015 Meniscal Allograft Transplantation

7.01.017 Cosmetic and Reconstructive Surgery with Attached Companion Table

7.01.018 Foot Care Services

7.01.020A Surgical Correction of Refractive Errors

7.01.022 Oral-Facial Pathology or Trauma

7.01.023 Percutaneous Electrical Nerve Stimulation (PENS)

7.01.025 Spinal Cord and Deep Brain Stimulation

7.01.029 Thermal Capsulorrhaphy for Joint Instability

7.01.030 Therapeutic Apheresis

7.01.032 Percutaneous Vertebroplasty and Kyphoplasty

7.01.033 Total Hip Resurfacing

7.01.035 Extracorporeal Shock Wave Lithotripsy for Gallstones

7.01.036 Obesity and Morbid Obesity

7.01.037 Electrophrenic Pacemaker

7.01.040 Cavernous Nerve Stimulation Device

7.01.041 Treatments for Urinary Incontinence

7.01.042 Percutaneous Intracranial Angioplasty With or Without Stent Insertion

7.01.044 Sinus Antrostomy Using Dilation Balloon

7.01.045 Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

7.01.047 Functional Neuromuscular Stimulation

7.01.048 Autologous Chondrocyte Implantation

7.01.050A Computer Assisted Navigational Techniques in Orthopedic Surgery

7.01.062 Lung Volume Reduction Surgery for Palliation of Severe Emphysema

7.01.067 Prolotherapy (Proliferative Therapy)

7.01.071 Prophylactic Mastectomy

7.01.073 Radiofrequency Ablation of Malignant Tumors of the Liver

7.01.074 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

7.01.075 Vagus Nerve Stimulation

7.01.076 Wireless Capsule Endoscopy (Enteral Camera)

7.01.078 Interpositional Spacer for Osteoarthritis of the Knee Joint

7.01.079 Laryngeal Denervation and Reinnervation for Laryngeal Dystonia

7.01.080 Transpupillary Thermotherapy

7.01.081 Photocoagulation of Macular Drusen

7.01.082 Surgical Treatment of Varicosities

7.01.083 Percutaneous Lysis of Epidural Adhesions

7.01.084 Spinal Manipulation Under Anesthesia

7.01.085 Ultrasound Guided Cryoablation of Benign Fibroadenomas of the Breast

7.01.086 Carotid Artery Angioplasty and Stenting

7.01.087 Automatic Implantable Cardioverter Defibrillator (AICD)

7.01.088 Vertebral Disc Replacement / Lumbar Disc Prosthesis

7.01.089 Infrared Coagulation for Internal Hemorrhoids

7.01.090 Pulmonary Vein Ablation / Isolation for Atrial Fibrillation

7.01.091 Minimally Invasive Intervertebral Disc Decompression Procedures for Low Back Pain

7.01.092 Intraspinous Vertebral Decompression Implantation for Spinal Stenosis

7.01.093 Total Ankle Arthroplasty / Replacement

7.01.094 Mechanical Embolus Retrieval for Acute Ischemic Stroke

7.01.095 Endoscopic Therapies for Gastroesophageal Reflux

7.01.096 Dynamic Spinal Stabilization

7.01.097 Gastric Electrical Stimulation

7.01.098 Cryosurgical Ablation of Renal Cell Carcinoma

7.01.099 Cryotherapy Dilation for Peripheral Arterial Disease

7.01.100 Cervical Vertebral Disc Replacement

7.01.101 Percutaneous Intervertebral Thermal Annuloplasty Procedures for Low Back Pain

7.01.102 Bronchial Thermoplasty for Control of Asthma

7.01.104 Radiofrequency Ablation of Malignant Tumors of the Lung

7.01.105 Endoscopic Radiofrequency Ablation for Barrett's Esophagus

7.01.106A Robotic-Assisted Surgery

7.01.107 Neurosurgical Interventions for Cervicogenic Headache / Occipital Neuralgia

7.01.108 Platelet Rich Plasma Injection for Musculoskeletal and Orthopedic Surgical Applications

7.01.109 Surgical Treatment of Femoroacetabular Impingement

7.01.110 Filtration Surgeries for Open Angle Glaucoma

7.01.111 Transanal Endoscopic Microsurgery (TEM)

Transplant

08. Rehabilitation Therapy

09. Anesthesia

10. Administrative

11. Laboratory/Pathology

99. Archived...01. Durable Medical Equipment

99. Archived...02. Medicine

99. Archived...04. OB/GYN/Reproduction

99. Archived...05. Prescription Drug

99. Archived...06. Radiology/Imaging

99. Archived...07. Surgery

99. Archived...08. Rehabilitation Therapy

99. Archived...11. Laboratory/Pathology

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Serving Maryland, the District of Columbia and portions of Virginia. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. � Registered trademark of the Blue Cross and Blue Shield Association. �' Registered trademark of CareFirst of Maryland, Inc.