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CG-ANC-04 Ambulance Services: Air and Water
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5/1/11
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4/16/13
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CG-DME-06 Pneumatic Compression Devices for Lymphedema
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11/17/06
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2/16/13
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CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
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9/17/11
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10/9/12
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CG-DME-10 Durable Medical Equipment
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5/7/07
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4/16/13
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CG-DME-28 Myoelectric Upper Extremity Prosthetic Devices
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5/18/07
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4/16/13
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CG-DME-31 Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, with or without Power Seating Systems, and Power Operated Vehicles (POVs)s
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7/2/07
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ECD 7/20/13
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CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
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4/21/10
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4/16/13
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CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use
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7/2/07
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1/8/13
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CG-DRUG-05 Recombinant Erythropoietin Products
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4/25/08
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2/16/13
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CG-DRUG-08 Pharmacotherapy for Gaucher Disease
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7/2/07
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2/16/13
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CG-DRUG-09 Immune Globulin (Ig) Therapy
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8/24/07
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4/16/13
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CG-DRUG-11 Oral, Injectable and Topical Infertility Drugs
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1/23/10
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1/8/13
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CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) Analogs
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1/23/10
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7/10/12
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CG-DRUG-16 White Blood Cell Growth Factors
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5/7/10
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ECD 5/18/13
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CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel)
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10/24/08
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ECD 5/18/13
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CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
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10/24/08
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7/10/12
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CG-DRUG-27 Clostridial Collagenase Histolyticum Injection
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5/1/11
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10/9/12
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CG-DRUG-28 Alglucosidase alfa (Lumizyme®, Myozyme®)
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5/1/11
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1/8/13
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CG-MED-19 Custodial Care
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7/13/07
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4/16/13
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CG-MED-23 Home Health [As of 03/17/12, applicable to some ASO accounts only]
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7/13/07
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ECD 7/20/13
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CG-MED-29 Inpatient Subacute Care
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7/13/07
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7/10/12
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CG-MED-31 Skilled Nursing Facility
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7/13/07
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10/9/12
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CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
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1/23/10
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7/10/12
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CG-MED-43 Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT)
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4/16/13
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4/16/13
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CG-REHAB-04 Physical Therapy
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12/15/06
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4/16/13
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CG-REHAB-05 Occupational Therapy
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3/9/07
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4/16/13
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CG-REHAB-06 Speech-Language Pathology Services [As of 07/16/11, National Account Members only]
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8/24/07
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4/16/13
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CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
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5/7/07
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4/16/13
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CG-REHAB-08 Private Duty Nursing in the Home Setting
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7/13/07
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ECD 7/20/13
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CG-REHAB-09 Acute Inpatient Rehabilitation
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7/2/07
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10/9/12
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CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
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5/18/07
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4/16/13
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CG-SURG-05 Maze Procedure
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12/8/12
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12/8/12
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CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
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9/17/11
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10/9/12
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CG-SURG-09 Temporomandibular Disorders
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9/17/11
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1/8/13
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CG-SURG-12 Penile Prosthesis Implantation
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8/24/07
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1/8/13
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CG-SURG-18 Septoplasty
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5/7/07
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10/9/12
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CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
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5/1/11
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12/8/12
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CG-SURG-27 Gender Reassignment
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7/18/09
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10/13/12
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CG-SURG-28 Transcatheter Uterine Artery Embolization
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5/7/07
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ECD 5/18/13
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CG-SURG-30 Tonsillectomy for Children
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7/14/12
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11/12/12
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CG-TRANS-02 Kidney Transplantation
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11/17/06
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1/8/13
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Outpatient Sleep Testing and Therapy Services
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Effective 3/1/2013, the health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty Health, Inc. (AIM), a separate company. AIM’s Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines are available at http://www.aimspecialtyhealth.com/gowebsleep. For certain health plan members, AIM also provides sleep diagnostic and treatment management services. By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us.
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Radiology
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The health plan uses diagnostic imaging management guidelines developed by AIM Specialty Health (AIM), a separate company. For certain health plan members as of 01/01/2011, AIM also provides radiology utilization management services.
The health plan also develops Diagnostic Imaging Medical Policies which may address a service described in an AIM Diagnostic Imaging Clinical Guideline. Where such Medical Policy exists, the health plan Medical Policy supersedes the AIM Diagnostic Imaging Clinical Guideline.
AIM's Diagnostic Imaging Clinical Guidelines are available at
By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us.
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Head & Neck Imaging
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CT of the Head
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4/1/11
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CTA of the Head: Cerebrovascular
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4/1/11
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MRI of the Head
|
4/1/11
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MRA of the Head: Cerebrovascular
|
4/1/11
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CT of the Orbit, Sella Turcica, Posterior Fossa and the Temporal Bone, including Mastoids
|
4/1/11
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MRI of the Orbit, Face, Neck
|
4/1/11
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CT of the Paranasal Sinus Maxillofacial Area
|
4/1/11
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MRI of the Temporomandibular Joints
|
4/1/11
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CT of the Neck (Soft Tissue)
|
4/1/11
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CTA of the Neck
|
4/1/11
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MRA of the Neck
|
4/1/11
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Chest Imaging
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CT of the Chest
|
4/1/11
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CTA of the Chest
|
4/1/11
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MRI of the Chest
|
4/1/11
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MRA of the Chest
|
4/1/11
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Cardiac Imaging
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Nuclear Cardiology - Myocardial Perfusion Imaging
|
4/1/11
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Nuclear Cardiology - Cardiac Blood Pool Imaging
|
4/1/11
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Nuclear Cardiology - Infarct Imaging
|
4/1/11
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Stress Echocardiography
|
3/1/12
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Transesophageal Echocardiography (TEE)
|
3/1/12
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Resting Transthoracic Echocardiography
|
3/1/12
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CT Cardiac (Structure)
|
4/1/11
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MRI – Cardiac
|
4/1/11
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Abdominal & Pelvic Imaging
|
|
|
CT of the Abdomen
|
4/1/11
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MRI of the Abdomen
|
4/1/11
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CTA/MRA of the Abdomen
|
4/1/11
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CTA of the Abdominal Aorta - Lower Extremity Run-off
|
4/1/11
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CT of the Pelvis
|
4/1/11
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|
MRI of the Pelvis
|
4/1/11
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|
CTA/MRA of the Pelvis
|
4/1/11
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CT of the Abdomen & Pelvis Combination
|
4/1/11
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Spine Imaging
|
|
|
CT of the Cervical Spine
|
4/1/11
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MRI of the Cervical Spine
|
4/1/11
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CT of the Thoracic Spine
|
4/1/11
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MRI of the Thoracic Spine
|
4/1/11
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CT of the Lumbar Spine
|
4/1/11
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MRI of the Lumbar Spine
|
4/1/11
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Upper Extremity Imaging
|
|
|
CT of the Upper Extremity
|
4/1/11
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MRI of the Upper Extremity (Any Joint)
|
4/1/11
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MRI of the Upper Extremity (Non-Joint)
|
4/1/11
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CTA/MRA Upper Extremity
|
4/1/11
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Lower Extremity Imaging
|
|
|
CT of the Lower Extremity
|
4/1/11
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MRI of the Lower Extremity (Joint & Non- Joint)
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4/1/11
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CTA/MRA of the Lower Extremity
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4/1/11
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