Excellus BCBS

  • Cervical Traction Devices (e.g., HomeTrac Deluxe, Saunders Cervical HomeTrac, Hydraulic, Over-The-Door, Pneumatic Cervical, Pronex) (PDF) Policy 1.01.47 (posted 5/12/14)
  • Breast Pumps (PDF) Policy 1.01.39 (posted 5/13/14)
  • Augmentative and Alternative Communication Systems: AAC, Dynavox, Introtalker, VoiceMate, Walker Talker, Say-It-All, Speech Generating Devices (SGD) (PDF) Policy 1.01.03 (posted 11/4/13)
  • Opioid Addiction Treatment (e.g., Buprenorphine, LAAM, Methadone Maintenance Treatment, Ultra-rapid Detoxification) (PDF) Policy 3.01.04 (posted 5/22/14)
  • Collagenase Clostridium Histolyticum (Xiaflex) for Fibroproliferative Disorders (PDF) Policy 5.01.15 (posted 1/14/14)
  • Wireless Capsule Endoscopy/Imaging for Examination of the Gastrointestinal (GI) Tract: AGILE Patency Capsule, Given® Capsule Camera, PillCam SB, PillCam ESO (PDF) Policy 6.01.27 (posted 9/15/14)
  • Virtual Colonoscopy (CT Colonography) (PDF) Policy 6.01.32 (posted 6/16/14)
  • Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD): ELF, EndoCinch, Endoluminal Fundoplication, Endoluminal Gastroplication, Enteryx, EsophyX, Gatekeeper, Plexiglas Microspheres, NDO Plicator System, Radiofrequency Esophageal Treatment, Stretta) (PDF) Policy 7.01.45 (posted 6/16/14)
  • Surgical Management of Obesity: Adjustable Gastric Band, Bariatric Surgery, Biliopancreatic Diversion, Duodenal Switch, Endobarrier, Gastric Bypass, Gastric Plication, Imbrication, Lap Band, Restorative Obesity Surgery, Ednoluminal [ROSE], Roux-en-Y, Sleeve Gastrectomy, Stomach Stapling, TOGA, Transoral or Vertical Banded Gastroplasty (PDF) Policy 7.01.29 (posted 5/14/14)
  • Plugs for Fistula Repair (PDF) Policy 7.01.86 (posted 6/16/14)
  • Magnetic Esophageal Ring for the Treatment of Gastroesophageal Reflux (GERD): Esophageal Sphincter Device, LINX™ System, Magnetic Sphincter Augmentation (PDF) Policy 7.01.89 (posted 3/4/14)
  • High Resolution Anoscopy (Anal Colposcopy) (PDF) Policy 2.01.49 (posted 12/9/13)
  • Gastric Electrical Stimulation and Gastric Pacing (PDF) Policy 7.01.64 (posted 6/16/14)
  • Fecal Incontinence, Radiofrequency Treatment (Secca procedure) (PDF) Policy 7.01.66 (posted 7/7/14)
  • Fecal Bacteriotherapy, Fecal microbiota therapy (FMT), Fecal transfusion, Fecal transplant, Human probiotic infusion (HPI), Intestinal microbiotia Transplantation (IMT), Microbiome, Stool transplant (PDF) Policy 2.01.48 (posted 8/4/14)
  • Esophageal pH Monitoring (Catheter Based, Catheter Free, Wireless/Bravo™) (PDF) Policy 2.01.44 (posted 8/4/14)
  • Cryosurgical Tumor Ablation (PDF) Policy 7.01.03 (posted 9/15/14)
  • External Insulin Pump Therapy for Diabetes, Continuous Subcutaneous Insulin Infusion (CSII) (PDF) Policy 10.01.04 (posted 1/8/14)
  • Continuous Glucose Monitoring Systems (e.g., MiniMed CGMS, Freestyle Navigator, GlucoWatch, DexCom STS, Interstitial Glucose Monitor) (PDF) Policy 1.01.30 (posted 8/29/13)
  • Varicosities/Varicose Veins, Treatment Alternatives to Vein Stripping and Ligation (e.g., Ambulatory, Stab or Transilluminated Powered Phlebectomy, ClariVein®, Endoluminal Radiofrequency Ablation, Endovenous Laser Ablation, Mechanochemical Endovenous Ablation, MOCA, Sclerotherapy, VNUS) (PDF) Policy 7.01.47 (posted 6/16/14)
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