Excellus BCBS

  • Percutaneous Posterior Tibial Nerve Stimulation (PPTNS) (PDF) Policy 8.01.22 (posted 3/26/14)
  • Microvascular Decompression for Hemifacial Spasms and Trigeminal Neuralgia (PDF) Policy 7.01.37 (posted 10/2/14)
  • Lysis of Epidural Adhesions, Adhesiolysis (PDF) Policy 7.01.73 (posted 1/14/14)
  • Evoked Potentials: Auditory, Brainstem Auditory, Somatosensory, Visual and Intraoperative Monitoring of Evoked Potentials (PDF) Policy 2.01.27 (posted 3/4/14)
  • Deep Brain Stimulation (PDF) Policy 7.01.23 (posted 7/7/14)
  • Skilled Nursing Facility (SNF) Care for Medicare Advantage Members (PDF) Policy 11.01.21 (posted 3/17/14)
  • Sex Reassignment Surgery: Gender Dysphoria, Gender Identity Disorder (GID), Gender Reassignment Surgery, Genital Correction Surgery, Genital Reassignment Surgery, Genital Reconstruction, Gender Realignment Surgery, Gender Confirmation Surgery, Intersex, Transsexualism, Transsexual Surgery (PDF) Policy 7.01.84 (posted 11/4/13)
  • Second Medical and Second Surgical Opinions, Confirmatory Consultation (PDF) Policy 10.01.10 (posted 6/25/14)
  • External Prosthetic Devices: C-leg, Intelligent prosthesis, microprocessor-controlled lower limbs, Ossur Rheo, Vacuum-assisted-socket system (VASS) (PDF) Policy 1.01.18 (posted 7/29/14)
  • Private Rooms (PDF) Policy 12.01.06 (posted 1/14/14)
  • Personal Care Aide (PCA) and Consumer Directed Personal Assistant (CDPA) Services for Medicaid Managed Care Contracts (PDF) Policy #11.01.24 (posted 8/29/13)
  • Periodontal Scaling and Root Planing (PDF) Policy 13.01.04 (posted 7/29/14)
  • Periodontal Maintenance (PDF) Policy 13.01.05 (posted 7/29/14)
  • Out of Area and Out of Network Services: Medicaid, Family Health Plus, Child Health Plus (PDF) Policy 11.01.20 (posted 7/1/14)
  • Out of Area/Out of Network Services (PDF) Policy 11.01.13 (posted 5/22/14)
  • Medically Necessary Services (PDF) Policy 11.01.15 (posted 1/14/14)
  • Medical Response to Contamination from Terrorist Attacks: Biological (e.g., Anthrax, Germ Warfare, Plague, Smallpox), Chemical, Radiation (PDF) Policy 11.01.09 (posted 7/29/14)
  • Medical/Non-Surgical Weight Management Programs and Services, Indirect Calorimetry (PDF) Policy 11.01.01 (posted 9/15/14)
  • Interfacility (Hospital-to-Hospital, Inpatient, Interhospital) Transfer of a Registered Inpatient (PDF) Policy 11.01.18 (posted 11/4/13)
  • Hyperbaric Oxygen Therapy (HBOT): Systemic or Topical, Topical Oxygen Wound Therapy (TOWT) (PDF) Policy 2.01.07 (posted 3/26/14)
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