Medical Protocols

• Actigraphy
• Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
• Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
• Allogeneic Pancreas Transplant
• Ambulance (Emergency)
• Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
• Amniotic Membrane and Amniotic Fluid
• Antigen Leukocyte Antibody Test
• Aqueous Shunts and Stents for Glaucoma
• Artificial Intervertebral Disc: Cervical Spine
• Artificial Intervertebral Disc: Lumbar Spine
• Artificial Pancreas Device Systems
• Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
• Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
• Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
• Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure
• Automated Percutaneous and Percutaneous Endoscopic Discectomy
• Autonomic Nervous System Testing
• Axial Lumbosacral Interbody Fusion

• Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
• Bariatric Surgery
• Bioengineered Skin and Soft Tissue Substitutes
• Biofeedback as a Treatment of Chronic Pain
• Biofeedback as a Treatment of Fecal Incontinence or Constipation
• Biofeedback as a Treatment of Headache
• Biofeedback as a Treatment of Urinary Incontinence in Adults
• Biofeedback for Miscellaneous Indications
• Bioimpedance Devices for Detection and Management of Lymphedema
• Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
• Blepharoplasty
• Bronchial Thermoplasty

• Cardiac Rehabilitation in the Outpatient Setting
• Cardiovascular Risk Panels
• Carrier Screening for Genetic Diseases
• Catheter Ablation as Treatment for Atrial Fibrillation
• Catheter Ablation for Cardiac Arrhythmias
• Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
• Chelation Therapy for Off-Label Uses
• Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss
• Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
• Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)
• Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
• Cochlear Implant
• Cognitive Rehabilitation
• Computed Tomography Perfusion Imaging of the Brain
• Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast
• Computer-Assisted Navigation for Orthopedic Procedure
• Confocal Laser Endomicroscopy
• Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
• Continuous Passive Motion in the Home Setting
• Cooling Devices Used in the Outpatient Setting
• Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
• Cosmetic vs. Reconstructive Surgery or Services
• Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
• Cryosurgical Ablation of Primary or Metastatic Liver Tumors
• Cytochrome P450 Genotyping
• Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

• Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
• Deep Brain Stimulation
• Dermatologic Applications of Photodynamic Therapy
• Diagnosis and Management of Idiopathic Environmental Intolerance and Intracellular Micronutrient Analysis
• Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
• Diagnosis and Treatment of Sacroiliac Joint Pain
• DNA-Based Testing for Adolescent Idiopathic Scoliosis
• Dopamine Transporter Imaging With Single-Photon Emission Computed Tomography
• Drug Testing in Pain Management and Substance Abuse Treatment
• Dynamic Posturography
• Dynamic Spinal Visualization

• Electrical Bone Growth Stimulation of the Appendicular Skeleton
• Electrical Stimulation for the Treatment of Arthritis
• Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
• Electromagnetic Navigation Bronchoscopy
• Electrostimulation and Electromagnetic Therapy for Treating Wounds
• Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
• Endometrial Ablation
• Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
• Endothelial Keratoplasty
• Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
• Endovascular Stent Grafts for Abdominal Aortic Aneurysms
• Endovascular Therapies for Extracranial Vertebral Artery Disease
• Enhanced External Counterpulsation
• Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
• Extracorporeal Photopheresis
• Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
• Extracranial Carotid Artery Stenting

• Facet Arthroplasty
• Facet Joint Denervation
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
• Fecal Microbiota Transplantation
• Functional Neuromuscular Electrical Stimulation

• Gastric Electrical Stimulation
• Gender Reassignment Surgery
• Gene Expression Testing in the Evaluation of Patients with Stable Ischemic Heart Disease
• Gene Expression-Based Assays for Cancers of Unknown Primary
• General Approach to Evaluating the Utility of Genetic Panels
• General Approach to Genetic Testing
• Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing
• Genetic Testing for Alpha1-Antitrypsin Deficiency
• Genetic Testing for Alzheimer Disease
• Genetic Testing for Breast Cancer Gene Expression Prognosis Assay
• Genetic Testing for Cardiac Ion Channelopathies
• Genetic Testing for Cystic Fibrosis
• Genetic Testing for Developmental Delay and Autism Spectrum Disorder
• Genetic Testing for Duchenne and Becker Muscular Dystrophy
• Genetic Testing for Epilepsy
• Genetic Testing for Familial Cutaneous Malignant Melanoma
• Genetic Testing for FAP and Lynch Syndrome
• Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome
• Genetic Testing for Hereditary Hearing Loss
• Genetic Testing for Hereditary Hemochromatosis
• Genetic Testing for Human Leukocyte Genes (HLA)
• Genetic Testing for Lactase Insufficiency
• Genetic Testing for Leukemia and Lymphoma
• Genetic Testing for Li-Fraumeni Syndrome
• Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment
• Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
• Genetic Testing for Mental Health Conditions
• Genetic Testing for Mitochondrial Disorders
• Genetic Testing for Noninvasive Prenatal Testing
• Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
• Genetic Testing for PTEN Hamartoma Tumor Syndrome
• Genetic Testing for Statin-Induced Myopathy
• Genetic Testing for Tamoxifen Treatment
• Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
• Genetic Testing for Warfarin Dose
• Genetic Testing of CADASIL Syndrome

• Heart Transplant
• Heart/Lung Transplant
• Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
• Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
• Hematopoietic Cell Transplantation for Autoimmune Diseases
• Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma
• Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
• Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
• Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
• Hematopoietic Cell Transplantation for Hodgkin Lymphoma
• Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
• Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
• Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
• Hematopoietic Cell Transplantation for Primary Amyloidosis
• Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia
• Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
• Hematopoietic Stem Cell Transplantation for Solid Tumors of Childhood
• Hip Resurfacing
• Hippotherapy
• Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
• Hyperbaric Oxygen Therapy

• Image-Guided Minimally Invasive Decompression for Spinal Stenosis
• Immune Cell Function Assay
• Implantable Bone-Conduction and Bone-Anchored Hearing Aids
• Implantable Cardioverter Defibrillators
• Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
• Implantation of Intrastromal Corneal Ring Segments
• In Vitro Chemoresistance and Chemosensitivity Assays
• Ingestible pH and Pressure Capsule
• Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
• Intensity-Modulated Radiotherapy: Abdomen and Pelvis
• Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
• Intensity-Modulated Radiotherapy: Central Nervous System Tumors
• Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
• Interspinous Fixation (Fusion) Devices
• Intra-Articular Hyaluronan Injections for Osteoarthritis
• Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas
• Intradialytic Parenteral Nutrition
• Intraoperative Neurophysiologic Monitoring
• Invasive Prenatal (Fetal) Diagnostic Testing
• Islet Transplantation
• Isolated Small Bowel Transplant

• Keratoprosthesis
• Kidney Transplant
• KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
• KRAS, NRAS, and BRAF Variant Analysis in Metastatic Colorectal Cancer

• Laboratory Testing for HIV Tropism
• Laboratory Tests for Heart Transplant Rejection
• Light Therapy for Psoriasis
• Light Therapy for Vitiligo
• Lipid Apheresis
• Liver Transplant and Combined Liver-Kidney Transplant
• Low-Level Laser Therapy
• Lung and Lobar Lung Transplant
• Lung Volume Reduction Surgery for Severe Emphysema
• Lysis of Epidural Adhesions

• Magnetic Resonance Imaging‒Targeted Biopsy of the Prostate
• Magnetic Resonance-Guided Focused Ultrasound
• Magnetoencephalography/Magnetic Source Imaging
• Manipulation Under Anesthesia
• Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
• Measurement of Serum Antibodies to Infliximab and Adalimumab
• Meniscal Allografts and Other Meniscal Implants
• Microprocessor-Controlled Prostheses for the Lower Limb
• Microwave Tumor Ablation
• Miscellaneous Genetic and Molecular Diagnostic Tests
• Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer
• Molecular Markers in Fine Needle Aspirates of the Thyroid
• Multigene Expression Assay for Predicting Recurrence in Colon Cancer
• Multimarker Serum Testing Related to Ovarian Cancer
• Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
• Myoelectric Prosthetic Components for the Upper Limb

• Negative Pressure Wound Therapy in the Outpatient Setting
• Nerve Graft With Radical Prostatectomy
• Neurofeedback
• Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
• Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease

• Occipital Nerve Stimulation
• Occlusion of Uterine Arteries Using Transcatheter Embolization
• Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus
• Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
• Optical Coherence Tomography of the Anterior Eye Segment
• Orthognathic Surgery
• Orthopedic Applications of Platelet-Rich Plasma
• Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)
• Orthoptic/Vision Therapy
• Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
• Outpatient Pulmonary Rehabilitation
• Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

• Panniculectomy and Abdominoplasty
• PathFinderTG® Molecular Testing
• Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
• Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation
• Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy
• Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
• Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
• Percutaneous Tibial Nerve Stimulation
• Percutaneous Vertebroplasty and Sacroplasty
• Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux
• Pharmacogenetic Testing for Pain Management
• Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines
• Photodynamic Therapy for Choroidal Neovascularization
• Placental and Umbilical Cord Blood as a Source of Stem Cells
• Plasma Exchange
• Plugs for Anal Fistula Repair
• Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
• Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
• Preimplantation Genetic Testing
• Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
• Prolotherapy
• Prophylactic Mastectomy
• Prostatic Urethral Lift
• Protein and Genetic Testing for Prostate Cancer

• Quantitative Sensory Testing

• Radioembolization for Primary and Metastatic Tumors of the Liver
• Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
• Radiofrequency Ablation of Primary or Metastatic Liver Tumors
• Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer
• Reconstructive Breast Surgery/Management of Breast Implants
• Reduction Mammaplasty for Breast-Related Symptoms

• Sacral Nerve Neuromodulation/Stimulation
• Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
• Scintimammography and Gamma Imaging of the Breast and Axilla
• Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
• Sensory Integration Therapy and Auditory Integration Therapy
• Small Bowel/Liver and Multivisceral Transplant
• Spinal Cord and Dorsal Root Ganglion Stimulation
• Stem Cell Therapy for Peripheral Arterial Disease
• Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
• Subtalar Arthroereisis
• Surgical Treatment of Bilateral Gynecomastia
• Surgical Treatment of Femoroacetabular Impingement
• Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
• Surgical Ventricular Restoration

• Technology Assessment
• Temporomandibular Joint Dysfunction
• Thermography
• Total Artificial Hearts and Implantable Ventricular Assist Devices
• Transanal Radiofrequency Treatment of Fecal Incontinence
• Transcatheter Aortic Valve Implantation for Aortic Stenosis
• Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
• Transcatheter Mitral Valve Repair
• Transcatheter Pulmonary Valve Implantation
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
• Transcutaneous Electrical Nerve Stimulation
• Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
• Transmyocardial Revascularization
• Treatment of Hyperhidrosis
• Treatment of Tinnitus
• Treatment of Varicose Veins/Venous Insufficiency
• Tumor Treatment Fields Therapy for Glioblastoma

• Ultrasound Accelerated Fracture Healing Device
• Urinary Tumor Markers for Bladder Cancer
• Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer

• Vagus Nerve Stimulation
• Vectra® DA Blood Test for Rheumatoid Arthritis
• Vertebral Axial Decompression
• Vestibular Function Testing
• Viscocanalostomy and Canaloplasty

• Wearable Cardioverter Defibrillators
• Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
• Whole Gland Cryoablation of Prostate Cancer
• Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon