| Acute Inpatient Rehabilitation Services* | |
| Airway Clearance Devices in the Ambulatory Setting* | C.11.01 |
| Ambulatory ECG Monitoring* | |
| Artificial Disc* | |
| Bariatric Surgery* | |
| Bioengineered Skin Substitutes* | |
| Bone Anchored Hearing Aid (BAHA)* | C.5.20 |
| Bone Growth Stimulation* | C.11.05 |
| Breast Reconstruction Post Mastectomy or Partial Mastectomy* | C.5.03 |
| Breast Reduction Surgery* | |
| CAR T Cell Therapy | C.6.30 |
| Cell-free DNA Testing for Fetal Aneuploidy | C.6.17 |
| Cochlear Implants* | |
| Continuous Glucose Monitoring Devices | C.11.09 |
| Continuous Passive Motion (CPM) Devices* | C.11.15 |
| Cosmetic and Reconstructive Surgery | C.5.14 |
| Cranial Orthotic Devices* | |
| Criteria for Rental, Replacement, Repair, Upgrade or Purchase of Durable Medical Equipment (DME) | C.11.18 |
| Deep Brain Stimulation* | |
| Dynamic Low-Load Prolonged-Duration Stretch (LLPS) Devices for Treatment of Contracture and Joint Stiffness | C.11.12 |
| Electric Tumor Treatment Fields (TTF) Device | C.11.23 |
| Endoscopic Myotomy Procedures for Treatment of Esophageal Achalasia and Gastroparesis | C.5.32 |
| Endoscopic Procedures & Non-Endoscopic Devices for Gastroesophageal Reflux Disease | C.5.27 |
| External Electrical Stimulators: Neuromuscular Electrical Stimulation (NMES), and Transcutaneous Electrical Nerve Stimulator (TENS)* | |
| Excimer Laser for Treatment of Psoriasis | C.6.28 |
| Endoscopic Procedures and Non-endoscopic Devices for Gastroesophageal Reflux Disease* | |
| Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions | C.5.11 |
| Gender Affirming Surgery | C.5.29 |
| Gender Affirming Surgery – ETF | C.5.36 |
| Genetic Testing | C.6.07 |
| Genetic Testing for Breast, Ovarian, Pancreatic or Prostate Cancer Syndromes including BRCA | C.6.21 |
| Heart Failure-Remote Monitoring (CardioMEMS™) | C.6.23 |
| Home Health Care* | |
| Home Phototherapy Devices (Narrowband UVB) | C.11.25 |
| Hospice Services | C.12.01 |
| Hospital Bed Rental/Purchase and Accessories* | |
| Hyperbaric Oxygen Therapy (HBOT)* | |
| Infertility Services | C.6.12 |
| Insulin Pump and Continuous Glucose Monitoring Systems* | |
| Left Atrial Appendage Closure | |
| Life-Sustaining Enteral Nutrition | C.6.05 |
| Long Term Acute Care (LTAC) | |
| Lymphedema* | |
| Manual Wheelchairs* | |
| Motorized Wheelchairs/Power Operated Vehicles (Scooters)* | |
| Negative Pressure Wound Therapy for Adults* | |
| Obstructive Sleep Apnea – Non-Surgical Treatment with Oral Appliance | C.11.06 |
| Obstructive Sleep Apnea – Surgical Treatment | C.5.04 |
| Patient Lift Equipment* | |
| Pectus Carinatum Orthotic Devices and Surgical Correction | C.11.27 |
| Pediatric Standing Frames or Stander* | |
| Penile Implants | |
| Peripheral Nerve Stimulation* | |
| Photodynamic Therapy* | |
| Platelet-Rich Plasma (PRP) Injections | C.13.01 |
| Prenatal/Preconception Genetic Testing to Determine Carrier State of a Parent or Prospective Parent | C.6.18 |
| Prolotherapy | C.16.13 |
| Proton Beam Therapy* | |
| Ptosis – Surgical Procedures* | |
| Radioembolization with Yttrium-90 Microspheres (TheraSphere and SIR-Spheres) | C.6.24 |
| Recurrent Pregnancy Loss | C.6.29 |
| Rhinoplasty / Septorhinoplasty* | |
| Robotic Procedures | C.5.19 |
| Skilled Nursing Facility (SNF) Services* | |
| Solid Organ and Hematopoietic Stem Cell Transplantation | C.5.17 |
| Spinal Cord Stimulation* | |
| Surgical Repair of Cartilage, Ligament, and Meniscal Defects of the Knee | C.5.33 |
| Surgical Treatment for Varicose Veins and Venous Insufficiency* | |
| Surgical Treatment of Temporomandibular Joint (TMJ) Disorders* | |
| Thermal Intradiscal Procedures | C.5.22 |
| Transcatheter Closure of Septal Defect | C.11.22 |
| Treatment of Obstructive Sleep Apnea Non-surgical* | |
| Treatment of Urinary and Fecal Incontinence | C.5.13 |
| Tumor Marker Genetics | C.6.34 |
| Vagus Nerve Stimulation for Seizure Disorders* | |
| Wearable Cardioverter Defibrillator* | |
| Whole Exome and Whole Genome Sequencing | C.6.35 |