Excellus BCBS

  • Extracorporeal Shock Wave Therapy (ESWT) for Muscoloskeletal Conditions and Soft Tissue Wounds: Lithotripsy, Orthotripsy, OssaTron®, EpoUltra®, SINOCUR®, Orbasone™, Orthospec™ (PDF) Policy 2.01.31 (posted 8/4/14)
  • Electrothermal Collagen Shrinkage for Orthopedic Conditions, Thermal Capsulorrhaphy (PDF) Policy 7.01.46 (posted 8/4/14)
  • Dynamic Adjustable Braces/Joint Extension Device (e.g., Dynasplint™, EMPI Advance™, LMB Proglide™, Ultraflex™) (PDF) Policy 1.01.35 (posted 3/17/14)
  • Cryotherapy, Cold Therapy, Ice Therapy (PDF) Policy 1.01.21 (posted 7/29/14)
  • Continuous Passive Motion Device (CPM) in the Home Setting (PDF) Policy 1.01.02 (posted 9/15/14)
  • Computerized Motion Diagnostic Imaging (CMDI), Gait Analysis (PDF) Policy 2.01.13 (posted 12/9/13)
  • Computer Assisted Navigation for Knee and Hip Arthroplasty: Orthopilot® Navigation Platform (PDF) Policy 7.01.67 (posted 9/15/14)
  • Bone Growth Stimulators (e.g., Electrical, Osteogenic, Sonic Accelerated Fracture Healing System - SAFHS, Ultrasonic) (PDF) Policy 7.01.40 (posted 5/12/14)
  • Automated Percutaneous and Endoscopic Discectomy: Stryker DeKompressor, Nucleotome, SpineJet Hydrodiscectomy (PDF) Policy 7.01.16 (posted 3/26/14)
  • Autologous Chrondrocyte Implantation (e.g., Carticel®, De Novo ET, DeNovo NT, Matrix-induced ACI, MACI, Minced cartilage, Neocartilage, Scaffold-induced ACI) (PDF) Policy 7.01.38 (posted 3/26/14)
  • Artificial Lumbar Intervertebral Disc (e.g., Charité, ProDisc) (PDF) Policy 7.01.63 (posted 1/23/14)
  • Artificial Cervical Intervertebral Discs (e.g., Bryan, Mobi-C, PCM [Porous Coated Motion] Cervical Disc®, Prestige®, ProDisc®, Secure-C) (PDF) Policy 7.01.80 (posted 1/23/14)
  • Plasmapheresis, Plasma Exchange and Apheresis, Rheopheresis (PDF) Policy 8.01.04 (posted 3/4/14)
  • Phlebotomy, Therapeutic (PDF) Policy 12.01.12 (posted 10/24/13)
  • Chelation Therapy (e.g., EDTA, Endrate, Desferal, BAL in oil, Cuprimine, Depen, Zinecard, Exjade, Post-chelator Challeng Urinary Metal Testing, Post-provocation urinary metal testing) (PDF) Policy 8.01.03 (posted 10/24/13)
  • Transcranial Magnetic Stimulation: Deep TMS device, NeuroStar TMS device, rTMS, TMS (PDF) Policy 3.01.09 (posted 5/7/14)
  • Standard Dialectical Behavioral Therapy (DBT) (PDF) Policy 3.01.10 (posted 5/22/14)
  • Psychological Testing (PDF) Policy 3.01.02 (posted 7/29/14)
  • Power Therapies for Post-traumatic Stress Disorder (PTSD): Emotional Freedom (EFT), Energy Therapies, Eye Movement Desensitization and Reprocessing (EMDR), Tapas Accupressure (TAT), Thought Field Therapy (TFT), Traumatic Incident Reduction (TIR), Visual Knesthetic Dissociation (VKD) (PDF) Policy 8.01.09 (posted 12/9/13)
  • Phototherapy/Light Therapy for Seasonal Affective Disorder (SAD) (PDF) Policy 1.01.24 (posted 11/4/13)
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