Excellus BCBS

  • Bioengineered Tissue Products (AlloDerm®, AlloMax™, AlloSkin™, Apligraf®, ArthroFlex™, Artificial skin, Avaulta Plus™, Biobrane®, Biobrane l®, Bioengineered skin, Biologic tissue, Collamend, Conexa™, Cymetra®, Dermagraft®, DermaMatrix, DermaSpan™, Endoform Dermal Template™, ENDURAgen™, Epicel®, EpiFix, E-Z Derm™, FlexHD®, GammaGraft, Grafix® CORE, Grafix® PRIME, GraftJacket®, GraftJacket® Xpress, Graftskin, hMatrix®, Hyalomatrix®, Integra™, Integra™ Bilayer Wound® Matrix, Integra™ Dermal Regeneration Matrix®, Integra™ Flowable Wound® Matrix, InteguPly™, Laserskin, Matristem® Micromatrix, Matristem® Wound Matrix, Matristem® Burn Matrix, Mediskin®, Neoform, OASIS® Wound Matrix, OASIS® Burn Matrix, OASIS® Ultra, Orcel™, Orthoadapt, Pelvicol, Pelvisoft, Permacol™, Primatrix, Restore, Skin substitute, StrataGraft, Strattice™, SurgiMend®, TheraSkin®, Tissuemend, TranCyte™, TranZgraft, Unite Biomatrix, Veritas® Collagen Matrix) (PDF) Policy 7.01.35 (posted 7/30/13)
  • Light and Laser Therapies for Dermatologic Conditions (BCLear Lamp, CureLight Broadband, Excilite Lamp, Levulan®, Kerastick®, Metvix®, Narrow Band Ultraviolet B, Psoralens, PUVA, Ultraviolet Light, UVA, UVB, VTRAC Lamp, XeCL, XTRAC) (PDF) Policy 8.01.21 (posted 10/2/14)
  • Growth Factors for Wound Healing and Other Conditions: Becaplermin, Platelet Derived Growth Factor (PDGF), Platelet Rich Plasma, Regranex (PDF) Policy 2.01.24 (posted 3/4/14)
  • Extracorporeal Photochemotheraphy/Photopheresis (PDF) Policy 8.01.01 (posted 1/14/14)
  • Allergy Testing (Allergen Specific IgE, Allergen Specific IgG, Challenge, Cytotoxic, Dipstick, Disk, Intracutaneous, Intradermal, Leukocyte Histamine Release, Mucous Membrane, Paddle, Patch, Percutaneous, Phadiatop, Prick, Provocation-Neutralization, RAST, Rinkel, Scratch, Serial Endpoint Titration, Skin End Point Titration, Skin) (PDF) Policy 2.01.10 (posted 10/2/14)
  • Allergen Immunotherapy: Injections. Sublingual Immunotherapy (PDF) Policy 2.01.11 (posted 9/15/14)
  • Transrectal Ultrasound (TRUS), Transrectal Echography (PDF) Policy 6.01.06 (posted 3/26/14)
  • Transcranial Doppler Ultrasound (PDF) Policy 6.01.18 (posted 1/14/14)
  • Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening: Electron Beam Computed Tomography (EBCT), Helical CT, Low-Dose CT, Spiral CT (PDF) Policy 6.01.19 (posted 9/26/14)
  • Nuclear Breast Imaging: Breast Specific Gamma Camera, BSGI, Gammagram, Miraluma, Radioimmunoscintigraphy, Scintigraphy, Scintimammography (PDF) Policy 6.01.02 (posted 3/4/14)
  • Real Time Image Guided Radiation Therapy: Beacon, Calypso, IGRT, 4D Localization (PDF) Policy 6.01.39 (posted 5/1/14)
  • Positron Emission Tomography (PET), Oncologic Applications (FDG PET, FDG SPECT) (PDF) Policy 6.01.29 (posted 5/1/14)
  • Positron Emission Tomography (PET) Non-Oncologic Applications (FDG PET) (PDF) Policy 6.01.07 (posted 7/30/14)
  • Positron Emission Tompgraphy (PET) Cardiac Applications (PDF) Policy #6.01.41 (posted 4/30/12)
  • Positron Emission Tomography (PET) Cardiac Applications (PDF) Policy #6.01.41 (posted 3/13/14)
  • Positional Magnetic Resonance Imaging (MRI): Dynamic, Extension, Flexion, Sitting, Standing, Upright, Vertical (PDF) Policy 6.01.36 (posted 12/9/13)
  • Noninvasive Measurement of Cardiac Bioimpedance: Impedance Cardiography (ICG), Thoracic Electrical Bioimpedance (TEB) (PDF) Policy 6.01.26 (posted 12/9/13)
  • Mammography: Direct Full-Field Digital and Digital Breast Tomosynthesis (e.g., Senographe, SenoScan, LORAD Digital Breast Imaging [LDBI], Mammomat Novation) (PDF) Policy 6.01.22 (posted 12/9/13)
  • Mammography: Computer Aided Detection (CAD): Image Checker System, MammoReader, R2 Checker, Second Look, RapidScreen (PDF) Policy 6.01.23 (posted 9/15/14)
  • Magnetic Resonance Spectroscopy (MRS) (PDF) Policy 6.01.03 (posted 7/7/14)
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