Excellus BCBS

  • Uterine Artery Occlusion in the Treatment of Uterine Fibroids: Uterine Artery/Fibroid Embolization (UAE/UFE), Uterine Artery Coagulation (PDF) Policy 4.01.04 (posted 12/9/13)
  • Sexual Dysfunction Device, Female (Vacuum Therapy, Eros-CTD) (PDF) Policy 1.01.36 (posted 1/8/14)
  • Obstetrical Ultrasound (PDF) Policy 6.01.42 (posted 3/17/14)
  • MRI Guided Focused Ultrasonic Tumor Ablation: MRgFUS, Exablate 2000 (PDF) Policy 4.01.09 (posted 12/9/13)
  • Home Uterine Activity Monitoring (HUAM) (PDF) Policy 1.01.13 (posted 10/24/13)
  • Home Birth by Certified Nurse Midwives for Managed Care, Child Health Plus, Family Health Plus and Medicaid Managed Care Contracts (PDF) Policy 11.01.23 (posted 5/22/14)
  • Female Sterilization (e.g., Adiana®, Essure®, Tubal Ligation) (PDF) Policy 4.01.07 (posted 9/15/14)
  • Endometrial Ablation: Her Option™, Hydro ThermAblator®, MEA System, Novasure™, Resectoscope, Rollerball, ThermaChoice®, Thermal Balloon Therapy (PDF) Policy 4.01.01 (posted 3/26/14)
  • Elective Medical Termination of Pregnancy/Abortion (e.g., Methotrexate, Mifeprestone, Mifeprex, Misoprostal, RU486) (PDF) Policy 5.01.08 (posted 12/9/13)
  • Cervical Cancer Screening and Human Papilloma Virus (HPV) Testing (e.g., Cervista™, Cobas® HPV test, DNA with PAP, HPV, HPV DNA testing, Human Papillomavirus, HC 2, Hybrid Capture 2, Pap/ Papanicolaou smear: Direct visualization, Monolayer, Optical; FocalPoint™, MonoPrep Pap Test (MPPT), PapSure®, Speculite®, Speculoscopy, SurePath, ThinPrep®) (PDF) Policy 2.02.04 (posted 6/16/14)
  • Breast Epithelial Cell Collection for Cytologic Analysis (e.g., Breast Duct Lavage, Breast Pap Test, HALO NAF Collection system) (PDF) Policy 7.01.50 (posted 6/16/14)
  • Assisted Reproductive Technologies (ART) for Infertility: COMET Assay, Hylaluronan Binding Assay (HBA), Microsurgical Testicular Sperm Extraction (MicroTESE), Sperm DNA Integrity, Sperm Chromatin Structure Assay (SCSA®), Sperm DNA Fragmentation Assay (SDFA™), TUNEL Assay, Artificial or Intrauterine Insemination (AI, IUI), Microsurgical Epididymal Sperm Aspiration (MESA), Testicular Sperm Extraction (TESE), Direct Intra-Peritoneal Insemination (DIPI), Gamete Intrafallopian Transfer (GIFT), Intracytoplasmic Sperm Injection (ICSI), In-vitro Fertilization (IVF), Zygote Intrafallopian Transfer (ZIFT) (PDF) Policy 4.01.05 (posted 7/29/14)
  • Immunizations/Vaccines (e.g., Hepatitis A, Hepatitis B, Human Papillomavirus [HPV, Cervarix, Gardasil], Meningococcal, Pneumococcal [Pneumovax 23, Prevnar], Rotavirus [Rotarix], Varicella [Varivax], Varicella Zoster [Zostavax]) (PDF) Policy 2.01.42 (posted 8/4/14)
  • Water-Induced Thermotherapy (WIT) as a Treatment of Benign Prostatic Hyperplasia: Hot Water Balloon Therapy, Thermoflex™ (PDF) Policy 7.01.57 (posted 6/16/14)
  • Bulking Agents for Treatment of Urinary or Fecal Incontinence (Bovine Collagen, Carbon Coated Beads, Coaptite®, Contigen®, Durasphere, GAX, Macroplastique®, Microballoons, Solesta, Teflon® Injections, Uryx®) (PDF) Policy 7.01.22 (posted 6/16/14)
  • Transurethral Microwave Thermotherapy (e.g., Prostatron, Targis, Urowave System, CoreTherm, Prolieve, TMx-2000, TUMT) (PDF) Policy 7.01.28 (posted 1/23/14)
  • Sacral Nerve Stimulation for Pelvic Floor Dysfunction (Incontinence, Neuromodulation, Urinary Retention) (PDF) Policy 7.01.10 (posted 1/23/14)
  • Prostate Cancer Screening, Detection and Monitoring (e.g., Digital Rectal Exam - DRE, PCA3Plus, Prostate Specific Antigen - PSA, Prostatic Acid Phosphatase - Male PAP Test) (PDF) Policy 10.01.05 (posted 3/26/14)
  • Pelvic Floor Electrical Stimulation (PFES) as a Treatment of Urinary or Fecal Incontinence, Intravaginal Stimulation (PDF) Policy 1.01.19 (posted 10/2/14)
  • Extracorporeal Magnetic Innervation (ExMi) for Urinary Incontinence (Neocontrol Therapy Chair) (PDF) Policy 8.01.08 (posted 1/14/14)
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