For the BLUECHOICE HEALTHPLAN OF SOUTH CAROLINA
Managed Medicaid Program

By Category

PW_B126828
Clinical UM Guidelines  
The clinical UM guidelines published on this website are not always used by all plans or lines of business. The clinical UM guidelines are available for adoption by plans or lines of business for review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.  
Alternatively, health plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to health plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner. 
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 effective 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.  
Third Party Criteria
In addition to documents developed and maintained by us for coverage decisions, we may adopt clinical utilization management criteria (UM guidelines) developed and maintained by third party organizations. Where we have developed a Medical Policy which addresses a service described in a Third Party Criteria (TPC) guideline, the health plan Medical Policy supersedes the TPC Guideline. 
Below are links to criteria utilized by some plans and lines of business:  
AIM Specialty Health (AIM)-The health plan uses guidelines developed by AIM Specialty Health (AIM), a separate company, to perform utilization management services for some procedures for certain health plan members. 
AIM Guidelines which may be adopted for use: 
• AIM Clinical Appropriateness Guidelines for Radiology (Adult & Pediatric) 
• AIM Clinical Appropriateness Guidelines for Sleep Disorder Management 
• AIM Musculoskeletal Clinical Appropriateness Guidelines: Spine Surgery, Joint Surgery, and Interventional Pain Management 
• AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures 
• AIM Cardiology Clinical Appropriateness Guidelines: Advanced Imaging of the Heart, Arterial Ultrasound, Percutaneous Coronary Intervention, and Diagnostic Coronary Angiography 
• AIM Radiation Oncology Clinical Appropriateness Guidelines: Radiation Oncology includes brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS) 
The UM guidelines applicable to the programs below are available at:   
By clicking on the link to AIM below, 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.  
 
 
 
Administrative  
CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
CG-ADMIN-02 Clinically Equivalent Cost Effective Services – Targeted Immune Modulators
 
Ancillary, Miscellaneous  
CG-ANC-03 Acupuncture
CG-ANC-04 Ambulance Services: Air and Water
CG-ANC-05 Ambulance Services: Ground; Emergent
CG-ANC-06 Ambulance Services: Ground; Non-Emergent
 
 
Behavioral Health  
CG-BEH-01 Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder
CG-BEH-14 Intensive In-home Behavioral Health Services
CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
 
 
Durable Medical Equipment  
The health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty HealthSM (AIM), a separate company. For certain health plan members, AIM also provides sleep diagnostic and treatment utilization management services.  
AIM Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines are available at http://www.aimspecialtyhealth.com/gowebsleep.  
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.  
 
CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
CG-DME-05 Cervical Traction Devices for Home Use
CG-DME-06 Pneumatic Compression Devices for Lymphadema
CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
CG-DME-08 Infant Home Apnea Monitors
CG-DME-09 Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion Pump During the Post-Operative Period
CG-DME-10 Durable Medical Equipment
CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia
CG-DME-13 Lower Limb Prosthesis
CG-DME-15 Hospital Beds and Accessories
CG-DME-16 Pressure Reducing Support Surfaces - Groups 1 , 2 & 3
CG-DME-18 Home Oxygen Therapy
CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes
CG-DME-20 Orthopedic Footwear
CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses
CG-DME-23 Lifting Devices for Use in the Home
CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs-Standard, Heavy Duty and Lightweight
CG-DME-25 Seat Lift Mechanisms
CG-DME-26 Back-Up Ventilators in the Home Setting
CG-DME-30 Prothrombin Time Self-Monitoring Devices
CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
CG-DME-35 Electric Breast Pumps
CG-DME-36 Pediatric Gait Trainers
CG-DME-37 Air Conduction Hearing Aids
CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices
CG-DME-40 Electrical Bone Growth Stimulation
CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
CG-DME-42 Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance
CG-DME-44 Electric Tumor Treatment Field (TTF)
CG-DME-45 Ultrasound Bone Growth Stimulation
CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs
 
 
Prescription Drugs  
CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use
CG-DRUG-03 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®) and Direct Thrombin Inhibitors in the Outpatient Setting
CG-DRUG-05 Recombinant Erythropoietin Products
CG-DRUG-08 Enzyme Replacement Therapy for Gaucher Disease
CG-DRUG-09 Immune Globulin (Ig) Therapy
CG-DRUG-11 Infertility Drugs
CG-DRUG-14 Dihydroergotamine Mesylate Injection for the Treatment of Migraine or Cluster Headaches in Adults
CG-DRUG-16 White Blood Cell Growth Factors
CG-DRUG-18 Nesiritide (Natrecor®)
CG-DRUG-19 Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women
CG-DRUG-20 Enfuvirtide (Fuzeon®)
CG-DRUG-21 Naltrexone (Vivitrol®) Injections for the Treatment of Alcohol and Opioid Dependence
CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel)
CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
CG-DRUG-27 Clostridial Collagenase Histolyticum Injection
CG-DRUG-28 Alglucosidase alfa (Lumizyme®)
CG-DRUG-29 Hyaluronan Injections
CG-DRUG-33 Palonosetron
CG-DRUG-34 Docetaxel (Docefrez™, Taxotere®)
CG-DRUG-38 Pemetrexed Disodium (Alimta®)
CG-DRUG-40 Bortezomib (Velcade®)
CG-DRUG-41 Zoledronic Acid
CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase)
CG-DRUG-43 Natalizumab (Tysabri®)
CG-DRUG-44 Pegloticase (Krystexxa®)
CG-DRUG-45 Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)
CG-DRUG-46 Fosaprepitant (Emend®)
CG-DRUG-47 Level of Care: Specialty Pharmaceuticals
CG-DRUG-48 Azacitidine (Vidaza®)
CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection
CG-DRUG-50 Paclitaxel, protein-bound (Abraxane®)
CG-DRUG-51 Romidepsin (Istodax®)
CG-DRUG-52 Temsirolimus (Torisel®)
CG-DRUG-53 Drug Dosage, Frequency, and Route of Administration
CG-DRUG-54 Agalsidase beta (Fabrazyme®)
CG-DRUG-55 Elosulfase alfa (Vimizim®)
CG-DRUG-56 Galsulfase (Naglazyme®)
CG-DRUG-57 Idurasufase (Elaprase®)
CG-DRUG-58 Laronidase (Aldurazyme®)
CG-DRUG-59 Testosterone Injectable
CG-DRUG-60 Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications
CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
CG-DRUG-62 Fulvestrant (FASLODEX®)
CG-DRUG-63 Levoleucovorin Products
CG-DRUG-64 FDA-Approved Biosimilar Products
CG-DRUG-65 Tumor Necrosis Factor Antagonists
CG-DRUG-66 Panitumumab (Vectibix®)
CG-DRUG-67 Cetuximab (Erbitux®)
CG-DRUG-68 Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
CG-DRUG-69 Ustekinumab (Stelara®)
CG-DRUG-70 Eribulin mesylate (Halaven®)
CG-DRUG-71 Ziv-aflibercept (Zaltrap®)
CG-DRUG-72 Pertuzumab (Perjeta®)
CG-DRUG-73 Denosumab (Prolia®, Xgeva®)
CG-DRUG-74 Canakinumab (Ilaris®)
CG-DRUG-75 Romiplostim (Nplate®)
CG-DRUG-76 Plerixafor Injection (Mozobil™)
CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo®)
CG-DRUG-78 Antihemophilic Factors and Clotting Factors
CG-DRUG-79 Siltuximab (Sylvant®)
CG-DRUG-80 Cabazitaxel (Jevtana®)
CG-DRUG-81 Tocilizumab (Actemra®)
CG-DRUG-82 Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension
CG-DRUG-83 Growth Hormone
CG-DRUG-84 Belimumab (Benlysta®)
CG-DRUG-85 Tesamorelin (Egrifta®)
CG-DRUG-86 Ocriplasmin (Jetrea®) Intravitreal Injection Treatment
CG-DRUG-87 Vedolizumab (Entyvio®)
CG-DRUG-88 Dupilumab (Dupixent®)
CG-DRUG-89 Implantable and Extended-Release Buprenorphine-Containing Products
CG-DRUG-90 Intravitreal Treatment for Retinal Vascular Conditions
CG-DRUG-91 Intravitreal Corticosteroid Implants
CG-DRUG-92 Alpha-1 Proteinase Inhibitor Therapy
CG-DRUG-93 Sarilumab (Kevzara®)
CG-DRUG-94 Rituximab (Rituxan®) for Non-Oncologic Indications
CG-DRUG-95 Belatacept (Nulojix®)
CG-DRUG-96 Ado-trastuzumab emtansine (Kadcyla®)
CG-DRUG-97 Rilonacept (Arcalyst®)
CG-DRUG-98 Bendamustine Hydrochloride
CG-DRUG-99 Elotuzumab (Empliciti™)
CG-DRUG-100 Interferon gamma-1b (Actimmune®)
CG-DRUG-101 Ixabepilone (Ixempra®)
CG-DRUG-102 Olaratumab (Lartruvo™)
CG-DRUG-103 Botulinum Toxin
CG-DRUG-104 Omalizumab (Xolair®)
CG-DRUG-105 Abatacept (Orencia®)
CG-DRUG-106 Brentuximab Vedotin (Adcetris®)
CG-DRUG-107 Pharmacotherapy for Hereditary Angioedema
CG-DRUG-108 Enteral Carbidopa and Levodopa Intestinal Gel Suspension
CG-DRUG-109 Asfotase Alfa (Strensiq™)
CG-DRUG-110 Naltrexone Implantable Pellets
CG-DRUG-111 Sebelipase alfa (KANUMA™)
CG-DRUG-112 Abaloparatide (Tymlos™) Injection
 
 
Genetics  
CG-GENE-01 Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
CG-GENE-02 Analysis of KRAS Status
CG-GENE-03 BRAF Mutation Analysis
CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
 
 
Laboratory/Pathology  
CG-LAB-03 Tropism Testing for HIV Management
CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
CG-LAB-10 Zika Virus Testing
CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals
CG-LAB-12 Testing for Oral and Esophageal Cancer
CG-LAB-13 Skin Nerve Fiber Density Testing
CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting
 
 
Medicine  
The health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty HealthSM (AIM), a separate company. For certain health plan members, AIM also provides sleep diagnostic and treatment utilization management services.  
AIM Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines are available at http://www.aimspecialtyhealth.com/gowebsleep.  
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.  
 
CG-MED-02 Esophageal pH Monitoring
CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures
CG-MED-08 Home Enteral Nutrition
CG-MED-19 Custodial Care
CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation
CG-MED-23 Home Health
CG-MED-24 Electromyography and Nerve Conduction Studies
CG-MED-26 Neonatal Levels of Care
CG-MED-28 Iontophoresis for Medical Indications
CG-MED-32 Ancillary Services for Pregnancy Complications
CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
CG-MED-35 Retinal Telescreening Systems
CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
CG-MED-38 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
CG-MED-39 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry
CG-MED-40 External Ambulatory Event Monitors to Detect Cardiac Arrhythmias
CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
CG-MED-42 Maternity Ultrasound in the Outpatient Setting
CG-MED-44 Holter Monitors
CG-MED-45 Transrectal Ultrasonography
CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring
CG-MED-47 Fundus Photography
CG-MED-48 Scrotal Ultrasound
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otacoustic Emissions (OAEs) for Hearing Disorders
CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials
CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies
CG-MED-52 Allergy Immunotherapy (Subcutaneous)
CG-MED-53 Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing
CG-MED-54 Strapping
CG-MED-55 Level of Care: Advanced Radiologic Imaging
CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography
CG-MED-57 Cardiac Stress Testing with Electrocardiogram
CG-MED-58 Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI
CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries
CG-MED-62 Resting Electrocardiogram Screening in Adults
CG-MED-63 Treatment of Hyperhidrosis
CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
CG-MED-65 Manipulation Under Anesthesia of the Spine and Joints other than the Knee
CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
CG-MED-67 Melanoma Vaccines
CG-MED-68 Therapeutic Apheresis
CG-MED-69 Inhaled Nitric Oxide
CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
CG-MED-71 Wound Care in the Home Setting
CG-MED-72 Hyperthermia for Cancer Therapy
CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
CG-MED-76 Magnetic Source Imaging and Magnetoencephalography
CG-MED-77 SPECT/CT Fusion Imaging
CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures
 
 
Orthotics/Prosthetics  
CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
CG-OR-PR-03 Custom-made Knee Braces
CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar
 
 
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. 
 
 
Rehabilitation Therapy  
CG-REHAB-02 Outpatient Cardiac Rehabilitation
CG-REHAB-03 Pulmonary Rehabilitation
CG-REHAB-04 Physical Therapy
CG-REHAB-05 Occupational Therapy
CG-REHAB-06 Speech-Language Pathology Services
CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
CG-REHAB-08 Private Duty Nursing in the Home Setting
CG-REHAB-10 Level of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services
CG-REHAB-11 Cognitive Rehabilitation
 
 
Surgery  
CG-SURG-01 Colonoscopy
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
CG-SURG-05 Maze Procedure
CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib
CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
CG-SURG-09 Temporomandibular Disorders
CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures
CG-SURG-11 Surgical Treatment for Dupuytren's Contracture
CG-SURG-12 Penile Prosthesis Implantation
CG-SURG-15 Endometrial Ablation
CG-SURG-17 Trigger Point Injections
CG-SURG-18 Septoplasty
CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
CG-SURG-25 Injection Treatment for Morton’s Neuroma
CG-SURG-27 Sex Reassignment Surgery
CG-SURG-28 Transcatheter Uterine Artery Embolization
CG-SURG-29 Lumbar Discography
CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
CG-SURG-31 Treatment of Keloids and Scar Revision
CG-SURG-32 Pain Management: Cervical, Thoracic & Lumbar Facet Injections
CG-SURG-33 Lumbar Fusion and Lumbar Total Disc Arthroplasty
CG-SURG-34 Diagnostic Infertility Surgery
CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
CG-SURG-36 Adenoidectomy
CG-SURG-37 Destruction of Pre-Malignant Skin Lesions
CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
CG-SURG-39 Pain Management: Epidural Steroid Injections
CG-SURG-40 Cataract Removal Surgery for Adults
CG-SURG-41 Surgical Strabismus Correction
CG-SURG-42 Cervical Fusion
CG-SURG-43 Knee Arthroscopy
CG-SURG-44 Coronary Angiography in the Outpatient Setting
CG-SURG-45 Bone Graft Substitutes
CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion
CG-SURG-47 Surgical Interventions for Scoliosis and Spinal Deformity
CG-SURG-48 Elective Percutaneous Coronary Interventions (PCI)
CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
CG-SURG-50 Assistant Surgeons
CG-SURG-51 Outpatient Cystourethroscopy
CG-SURG-52 Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services
CG-SURG-53 Elective Total Hip Arthroplasty
CG-SURG-54 Elective Total Knee Arthroplasty
CG-SURG-55 Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
CG-SURG-57 Diagnostic Nasal Endoscopy
CG-SURG-58 Radioactive Seed Localization of Nonpalpable Breast Lesions
CG-SURG-59 Vena Cava Filters
CG-SURG-60 Cervical Total Disc Arthroplasty
CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the Liver
CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside the Liver
CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
CG-SURG-65 Recombinant Human Bone Morphogenetic Protein
CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
CG-SURG-67 Treatment of Osteochondral Defects
CG-SURG-68 Surgical Treatment of Femoracetabular Impingement Syndrome
CG-SURG-69 Meniscal Allograft Transplantation of the Knee
CG-SURG-70 Gastric Electrical Stimulation
CG-SURG-71 Reduction Mammaplasty
CG-SURG-72 Endothelial Keratoplasty
CG-SURG-73 Balloon Sinus Ostial Dilation
CG-SURG-74 Total Ankle Replacement
CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
CG-SURG-77 Refractive Surgery
CG-SURG-78 Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
CG-SURG-79 Implantable Infusion Pumps
CG-SURG-80 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
CG-SURG-85 Hip Resurfacing
CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
CG-SURG-88 Mastectomy for Gynecomastia
CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
CG-SURG-90 Mohs Micrographic Surgery
CG-SURG-91 Minimally Invasive Ablative Procedures for Epilepsy
 
 
Therapeutic Radiology  
CG-THER-RAD-03 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy
CG-THER-RAD-04 Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors
CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)
 
 
Transplant  
CG-TRANS-02 Kidney Transplantation
CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
 

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.