For the BLUECHOICE HEALTHPLAN OF SOUTH CAROLINA
Managed Medicaid Program

By Category

PW_B126824
Medical Policies  
Medical policies are used by all plans and lines of business unless Federal or State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy. Those provisions will be considered first in determining eligibility for coverage before the medical policy is used to determine medical necessity.  
Note: In addition to documents developed and maintained by us for coverage decisions, we may adopt for use criteria developed and maintained by third party organizations.  
Dates associated with medical policies and clinical UM guidelines
Each medical policy and clinical UM guideline includes a Last Review Date and Publish Date. A medical policy or clinical UM guideline is made available on our public websites on its Publish Date. While the Publish Date is enterprise-wide, the actual implementation date may differ, depending on notification requirements. Local health plans will determine if new or revised medical policies and clinical UM guidelines require advance provider notification, based upon state laws, provider contracts and other considerations.  
Medical policy and clinical UM guidelines do not contain an implementation date which is the date that a health plan may begin using the new or updated medical policy or clinical UM guideline. The Implementation Date may be the same as the Publish Date when an updated document is an expansion of current criteria. When a new document or an update to an existing document that is more restrictive is published, the implementation date is determined by the local health plan since requirements regarding provider notification vary based upon state laws, provider contracts and other considerations.  
 
 
 
Administrative 
ADMIN.00001 Medical Policy Formation
ADMIN.00002 Preventive Health Guidelines
ADMIN.00004 Medical Necessity Criteria
ADMIN.00005 Investigational Criteria
ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
ADMIN.00007 Immunizations
 
Ancillary, Miscellaneous 
ANC.00006 Biomagnetic Therapy
ANC.00007 Cosmetic and Reconstructive Services: Skin Related
ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
 
 
Behavioral Health 
BEH.00002 Transcranial Magnetic Stimulation
 
 
Durable Medical Equipment 
DME.00009 Vacuum Assisted Wound Therapy in the Outpatient Setting
DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
DME.00012 Intrapulmonary Percussive Ventilation Devices for Airway Clearance
DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease `
DME.00025 Self-Operated Spinal Unloading Devices
DME.00030 Altered Auditory Feedback Devices for the Treatment of Stuttering
DME.00032 Automated External Defibrillators for Home Use
DME.00034 Standing Frames
DME.00037 Cooling Devices and Combined Cooling/Heating Devices
DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
DME.00039 Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
 
 
Prescription Drug  
DRUG.00003 Chelation Therapy
DRUG.00013 Administration of Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
DRUG.00015 Prevention of Respiratory Syncytial Virus Infections
DRUG.00027 Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain
DRUG.00031 Subcutaneous Hormone Replacement Implants
DRUG.00034 Insulin Potentiation Therapy
DRUG.00046 Ipilimumab (Yervoy®)
DRUG.00050 Eculizumab (Soliris®)
DRUG.00053 Carfilzomib (Kyprolis®)
DRUG.00062 Obinutuzumab (Gazyva®)
DRUG.00063 Ofatumumab (Arzerra®)
DRUG.00067 Ramucirumab (Cyramza®)
DRUG.00071 Pembrolizumab (Keytruda®)
DRUG.00074 Alemtuzumab (Lemtrada®)
DRUG.00075 Nivolumab (Opdivo®)
DRUG.00076 Blinatumomab (Blincyto®)
DRUG.00077 Monoclonal Antibodies to Interleukin-17A
DRUG.00078 Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
DRUG.00080 Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
DRUG.00081 Eteplirsen (Exondys 51™)
DRUG.00082 Daratumumab (DARZALEX™)
DRUG.00086 Mecasermin (Increlex®)
DRUG.00088 Atezolizumab (Tecentriq™)
DRUG.00090 Bezlotoxumab (ZINPLAVA™)
DRUG.00095 Ocrelizumab (Ocrevus®)
DRUG.00096 Ibalizumab-uiyk (Trogarzo™)
DRUG.00099 Cerliponase Alfa (Brineura™)
DRUG.00104 Nusinersen (SPINRAZA®)
DRUG.00107 Avelumab (Bavencio®)
DRUG.00108 Edaravone (Radicava®)
DRUG.00109 Durvalumab (Imfinzi®)
DRUG.00110 Inotuzumab ozogamicin (Besponsa®)
DRUG.00111 Monoclonal Antibodies to Interleukin-23
DRUG.00112 Gemtuzumab Ozogamicin (Mylotarg®)
DRUG.00116 Vestronidase alfa (Mepsevii™)
DRUG.00118 Copanlisib (Aliqopa®)
 
 
Genetics  
GENE.00001 Genetic Testing for Cancer Susceptibility
GENE.00002 Preimplantation Genetic Diagnosis Testing
GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer’s Disease
GENE.00005 BCR-ABL Mutation Analysis
GENE.00006 Epidermal Growth Factor Receptor (EGFR) Testing
GENE.00007 Cardiac Ion Channel Genetic Testing
GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment
GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
GENE.00016 Gene Expression Profiling for Colorectal Cancer
GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)
GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site
GENE.00020 Gene Expression Profile Tests for Multiple Myeloma
GENE.00021 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
GENE.00023 Gene Expression Profiling of Melanomas
GENE.00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis
GENE.00025 Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors
GENE.00026 Cell-Free Fetal DNA-Based Prenatal Testing
GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility
GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome
GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility
GENE.00031 Genetic Testing for PTEN Hamartoma Tumor Syndrome
GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies
GENE.00034 SensiGene® Fetal RhD Genotyping Test
GENE.00035 Genetic Testing for TP53 Mutations
GENE.00036 Genetic Testing for Hereditary Pancreatitis
GENE.00037 Genetic Testing for Macular Degeneration
GENE.00038 Genetic Testing for Statin-Induced Myopathy
GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
GENE.00040 Genetic Testing for CHARGE Syndrome
GENE.00041 Genetic Testing to Confirm the Identity of Laboratory Specimens
GENE.00042 Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases
GENE.00044 Analysis of PIK3CA Status in Tumor Cells
GENE.00045 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
GENE.00046 Prothrombin G20210A (Factor II) Mutation Testing
GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing
GENE.00049 Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
 
 
Laboratory  
LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
LAB.00011 Analysis of Proteomic Patterns
LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders
LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
LAB.00024 Immune Cell Function Assay
LAB.00025 Topographic Genotyping
LAB.00026 Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests
LAB.00028 Serum Biomarker Tests for Multiple Sclerosis
LAB.00029 Rupture of Membranes Testing in Pregnancy
LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
LAB.00031 Advanced Lipoprotein Testing
LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
LAB.00034 Serological Antibody Testing For Helicobacter Pylori
LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
 
 
Medicine  
MED.00002 Selected Sleep Testing Services
MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
MED.00007 Prolotherapy for Joint and Ligamentous Conditions
MED.00011 Sensory Stimulation for Brain-Injured Patients in Coma or Vegetative State
MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
MED.00024 Adoptive Immunotherapy and Cellular Therapy
MED.00041 Microvolt T-Wave Alternans
MED.00053 Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting
MED.00055 Wearable Cardioverter Defibrillators
MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
MED.00059 Idiopathic Environmental Illness (IEI)
MED.00065 Hepatic Activation Therapy
MED.00074 Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
MED.00077 In-Vivo Analysis of Gastrointestinal Lesions
MED.00082 Quantitative Sensory Testing
MED.00085 Antineoplaston Therapy
MED.00087 Imaging Techniques for Screening and Identification of Cervical Cancer
MED.00089 Quantitative Muscle Testing Devices
MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
MED.00091 Rhinophototherapy
MED.00092 Automated Nerve Conduction Testing
MED.00095 Anterior Segment Optical Coherence Tomography
MED.00096 Low-Frequency Ultrasound Therapy for Wound Management
MED.00097 Neural Therapy
MED.00098 Hyperoxemic Reperfusion Therapy
MED.00099 Electromagnetic Navigational Bronchoscopy
MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
MED.00102 Ultrafiltration in Decompensated Heart Failure
MED.00103 Automated Evacuation of Meibomian Gland
MED.00104 Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
MED.00106 Sipuleucel-T (Provenge®)
MED.00109 Corneal Collagen Cross-Linking
MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
MED.00111 Intracardiac Ischemia Monitoring
MED.00112 Autonomic Testing
MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
MED.00116 Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium
MED.00118 Continuous Monitoring of Intraocular Pressure
MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications
MED.00120 Voretigene neparvovec-rzyl (Luxturna™)
MED.00121 Implantable Interstitial Glucose Sensors
MED.00122 Wilderness Programs
MED.00123 Axicabtagene ciloleucel (Yescarta®)
MED.00124 Tisagenlecleucel (Kymriah®)
MED.00125 Biofeedback and Neurofeedback
MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
 
 
Orthotics/Prosthetics  
OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis
OR-PR.00004 Partial-Hand Myoelectric Prosthesis
OR-PR.00005 Upper Extremity Myoelectric Orthoses
OR-PR-00006 Powered Robotic Lower Body Exoskeleton Devices
 
 
Radiology  
The health plan uses diagnostic imaging management guidelines developed by AIM Specialty Health (AIM), a separate company. For certain health plan members, AIM also provides radiology utilization management services. 
The health plan also develops Diagnostic Imaging Medical Policies which may address a service described in an AIM Diagnostic Imaging Clinical Guideline. Where such Medical Policy exists, the health plan Medical Policy supersedes the AIM Diagnostic Imaging Clinical Guideline.  
AIM's Diagnostic Imaging Clinical Guidelines are available at http://www.aimspecialtyhealth.com/marketing/guidelines/185/index.html
By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us. 
 
RAD.00001 Computed Tomography to Detect Coronary Artery Calcification
RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
RAD.00004 Peripheral Bone Mineral Density Measurement
RAD.00012 Ultrasound for the Evaluation of Paranasal Sinuses
RAD.00023 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
RAD.00036 MRI of the Breast
RAD.00037 Whole Body Computed Tomography Scanning
RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
RAD.00040 PET Scanning Using Gamma Cameras
RAD.00044 Magnetic Resonance Neurography
RAD.00052 Positional MRI
RAD.00053 Cervical and Thoracic Discography
RAD.00054 MRI of the Bone Marrow
RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
RAD.00059 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord
RAD.00061 PET/MRI
RAD.00062 Intravascular Optical Coherence Tomography (OCT)
RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
RAD.00065 Radiostereometric Analysis (RSA)
RAD.00066 Multiparametric Magnetic Resonance Imaging Fusion Targeted Prostate Biopsy
 
 
Rehabilitation  
REHAB.00003 Hippotherapy
 
 
Surgery  
SURG.00005 Partial Left Ventriculectomy
SURG.00007 Vagus Nerve Stimulation
SURG.00008 Mechanized Spinal Distraction Therapy
SURG.00010 Treatments for Urinary Incontinence
SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
SURG.00016 Stereotactic Radiofrequency Pallidotomy
SURG.00019 Transmyocardial Revascularization
SURG.00022 Lung Volume Reduction Surgery
SURG.00023 Breast Procedures, including Reconstructive Surgery, Implants and Other Breast Procedures
SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
SURG.00033 Cardioverter Defibrillators
SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
SURG.00037 Treatment of Varicose Veins (Lower Extremities)
SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
SURG.00044 Breast Ductal Examination and Fluid Cytology Analysis
SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions
SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
SURG.00048 Panniculectomy and Abdominoplasty
SURG.00052 Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty) [IDB])
SURG.00053 Unicondylar Interpositional Spacer
SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence
SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
SURG.00062 Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
SURG.00066 Percutaneous Neurolysis for Chronic Neck and Back Pain
SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
SURG.00070 Photocoagulation of Macular Drusen
SURG.00071 Percutaneous and Endoscopic Spinal Surgery
SURG.00072 Lysis of Epidural Adhesions
SURG.00073 Epiduroscopy
SURG.00075 Intervertebral Stabilization Devices
SURG.00076 Nerve Graft after Prostatectomy
SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
SURG.00079 Nasal Valve Suspension
SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
SURG.00084 Implantable Middle Ear Hearing Aids
SURG.00088 Coblation® Therapies for Musculoskeletal Conditions
SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation
SURG.00092 Implanted Devices for Spinal Stenosis
SURG.00095 Viscocanalostomy and Canaloplasty
SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
SURG.00097 Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke
SURG.00099 Convection Enhanced Delivery of Therapeutic Agents to the Brain
SURG.00100 Cryoablation for Plantar Fasciitis and Plantar Fibroma
SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent
SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
SURG.00105 Biocompartmental Knee Arthroplasty
SURG.00106 Ablative Techniques as a Treatment for Barrett’s Esophagus
SURG.00107 Prostate Saturation Biopsy
SURG.00111 Axial Lumbar Interbody Fusion
SURG.00112 Occipital Nerve and Supraorbital Nerve Stimulation
SURG.00113 Artificial Retinal Devices
SURG.00114 Facet Joint Allograft Implants for Facet Disease
SURG.00115 Keratoprosthesis
SURG.00116 High-Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
SURG.00117 Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention
SURG.00118 Bronchial Thermoplasty
SURG.00119 Endobronchial Valve Devices
SURG.00120 Internal Rib Fixation Systems
SURG.00121 Transcatheter Heart Valve Procedures
SURG.00122 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
SURG.00123 Transmyocardial/Perventricular Device Closure of a Ventricular Septal Defects
SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
SURG.00126 Irreversible Electroporation
SURG.00127 Sacroiliac Joint Fusion
SURG.00128 Implantable Left Atrial Hemodynamic Monitor
SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
SURG.00130 Annulus Closure After Discectomy
SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency
SURG.00133 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
SURG.00134 Interspinous Process Fixation Devices
SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves
SURG.00136 Intraocular Telescope
SURG.00137 Focused Microwave Thermotherapy for Breast Cancer
SURG.00138 Laser Treatment of Onychomycosis
SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain
SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization
SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
SURG.00146 Extracorporeal Carbon Dioxide Removal
SURG.00147 Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
SURG.00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
SURG.00149 Percutaneous Ultrasonic Ablation of Soft Tissue
SURG.00150 Leadless Pacemakers
SURG.00151 Balloon Dilation of Eustachian Tube
 
 
Therapeutic Radiology  
THER-RAD.00008 Neutron Beam Radiotherapy
THER-RAD.00009 Intraocular Epiretinal Brachytherapy
 
 
Transplant  
TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
TRANS.00008 Liver Transplantation
TRANS.00009 Lung and Lobar Transplantation
TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation
TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
TRANS.00026 Heart/Lung Transplantation
TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
TRANS.00033 Heart Transplantation
TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
TRANS.00035 Mesenchymal Stem Cell Therapy For Orthopedic Indications
TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease
 

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

Medicaid managed care administered by Amerigroup Partnership Plan, LLC, an independent company.