Coverage guideline informational notice

Archived coverage guideline numbers effective September 20, 2018

 

The following coverage guideline numbers have been archived:

DME.00027 Ultrasound Bone Growth Stimulation [Note: Content of DME.00027 has been transferred to new clinical UM guideline CG-DME-45.] 

DRUG.00006 Botulinum Toxin [Note: Content of DRUG.00006 has been transferred to clinical UM guideline CG-DRUG-103.]  

DRUG.00024 Omalizumab (Xolair®) [Note: Content of DRUG.00024 has been transferred to new clinical UM guideline CG-DRUG-104.]

DRUG.00040 Abatacept (Orencia) [Note: Content of DRUG.00040 has been transferred to clinical UM guideline CG-DRUG-105.]

DRUG.00047 Brentuximab Vedotin (Adcetris®) [Note: Content of DRUG.00047 has been transferred to new clinical UM guideline CG-DRUG-106.]

DRUG.00058 Pharmacotherapy for Hereditary Angioedema [Note: Content of DRUG.00058 has been transferred to new clinical UM guideline CG-DRUG-107.]

DRUG.00064 Enteral Carbidopa and Levodopa Intestinal Gel Suspension  [Note: Content of DRUG.00064 has been transferred to new clinical UM guideline CG-DRUG-108.]

DRUG.00087 Asfotase Alfa (Strensiq™) [Note: Content of DRUG.00087 has been transferred to new clinical UM guideline CG-DRUG-109.]

DRUG.00091 Naltrexone Implantable Pellets [Note: Content of DRUG.00091 has been transferred to new clinical UM guideline CG-DRUG-110.]

DRUG.00093 Sebelipase alfa (KANUMA™) [Note: Content of DRUG.00093 has been transferred to new clinical UM guideline CG-DRUG-111.]

DRUG.00103 Abaloparatide (Tymlos™) [Note: Content of DRUG.00103 has been transferred to new clinical UM guideline CG-DRUG-112.]

MED.00005 Hyperbaric Oxygen Therapy (Systemic/Topical) [Note: Content of MED.00005 has been transferred to new clinical UM guideline CG-MED-73.]

MED.00051 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry [Note: Content of MED.00051 has been transferred to new clinical UM guideline CG-MED-74.]

 

MED.00081 Cognitive Rehabilitation [Note: Content of MED.00081 has been transferred to new clinical UM guideline CG-REHAB-11.]

MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome [Note: Content of MED.00107 has been transferred to new clinical UM guideline CG-MED-75.]

RAD.00019 Magnetic Source Imaging and Magnetoencephalography [Note: Content of RAD.00019 has been transferred to new clinical UM guideline CG-MED-76.]

RAD.00042 SPECT/CT Fusion Imaging [Note: Content of RAD.00042 has been transferred to new clinical UM guideline CG-MED-77.]

SURG.00014 Cochlear Implants and Auditory Brainstem Implants [Note: Content of SURG.00014 has been transferred to new clinical UM guideline CG-SURG-81.]

SURG.00020 Bone-Anchored and Bone Conduction Hearing Aids [Note: Content of SURG.00020 has been transferred to new clinical UM guideline CG-SURG-82.]

SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity [Note: Content of SURG.00024 has been transferred to new clinical UM guideline CG-SURG-83.]

SURG.00049 Mandibular/ Maxillary (Orthognathic) Surgery [Note: Content of SURG.00049 has been transferred to new clinical UM guideline CG-SURG-84.]

SURG.00051 Hip Resurfacing [Note: Content of SURG.00051 has been transferred to new clinical UM guideline CG-SURG-85.]

SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection [Note: Content of SURG.00054 has been transferred to new clinical UM guideline CG-SURG-86.]

SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring [Note: Content of SURG.00074 has been transferred to new clinical UM guideline CG-SURG-87.]

SURG.00085 Mastectomy for Gynecomastia [Note: Content of SURG.00085 has been transferred to new clinical UM guideline CG-SURG-88.]

SURG.00090 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia [Note: Content of SURG.00090 has been transferred to new clinical UM guideline CG-SURG-89.]

TRANS.00018 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation [Note: Content of TRANS.00018 has been transferred to new clinical UM guideline CG-TRANS-03.]