A-H | I-Q | R-Z |
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25-Hydroxyvitamin D testing in Children and Adolescents (PDF)
Effective Date: 12/29/17 | Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
Effective Date: 4/30/18 | Radial Head Implant (PDF)
Effective Date: 5/31/18 |
Acupuncture (PDF)
Effective Date: 11/30/17 | Inhaled Nitric Oxide (PDF)
Effective Date: 9/30/17 | Reduction Mammoplasty and Gynecomastia Surgery (PDF)
Effective Date: 7/31/18 |
ADHD Assessment and Treatment (PDF)
Effective Date: 02/2022 | Intensity-Modulated Radiotherapy (PDF)
Effective Date: 2/28/18 | Sacroiliac Joint Fusion (PDF)
Effective Date: 6/30/18 |
Allergy Testing and Therapy (PDF)
Effective Date: 05-14-21 | Intestinal and Multivisceral Transplant (PDF)
Effective Date: 6/30/18 | Sacroiliac Joint Interventions for Pain Management (PDF)
Effective Date: 8/31/2018 |
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF)
Effective Date: 2/28/18 | Intradiscal Steroid Injections for Pain Management (PDF)
Effective Date: 8/31/2018 | Sclerotherapy for Vericose Veins (PDF)
Effective Date: 4/30/18 |
Ambulatory EEG (PDF)
Effective Date: 7/31/20 | Laser Therapy for Skin Conditions (PDF)
Effective Date: 6/30/18 | Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Effective Date: 8/31/2018 |
Ambulatory Surgery Center Optimization (PDF)
Effective Date: 2/16/18 | Long Term Care Placement Criteria (PDF)
Effective Date: 4/30/18 | Sickle Cell Disease Observation (PDF)
Effective Date: 7/31/18 |
Applied Behavioral Analysis (PDF)
Effective Date: 1/31/18 | Low-frequency Ultrasound Therapy for Wound Management (PDF)
Effective Date: 1/31/18 | Spinal Cord Stimulation (PDF)
Effective Date: 5/31/18 |
Articular Cartilage Defect Repairs (PDF)
Effective Date: 4/30/18 | Lung Transplantation (PDF)
Effective Date: 11/30/17 | Stereotactic Body Radiation Therapy (PDF)
Effective Date: 1/31/18 |
Assisted Reproductive Technology (PDF)
Effective Date: 3/31/18 | Lysis of Epidural Lesions (PDF)
Effective Date: 5/31/18 | Tandem Transplant (PDF)
Effective Date: 7/31/18 |
Balloon Sinus Ostial Dilation (PDF)
Effective Date: 11/31/17 | Measurement of Serum 1,25-Dihydroxyvitamin D (PDF)
Effective Date: 12/29/2017 | Testing for Rupture of Fetal Membranes (PDF)
Effective Date: 6/30/18 |
Bariatric Surgery (PDF)
Effective Date: 6/30/18 | Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
Effective Date: 3/31/18 | Testing for Select Genitourinary Conditions (PDF)
Effective Date: 03/2022 |
Biofeedback (PDF)
Effective Date: 5/31/18 | Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: 5/31/18 | Therapy Services (PT/OT/ST) (PDF)
Effective Date: 6/22/18 |
Bone-anchored Hearing Aid (PDF)
Effective Date: 12/31/17 | Multiple Sleep Latency Testing (PDF)
Effective Date: 4/30/18 | Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: 12/29/17 |
Bronchial Thermoplasty (PDF)
Effective Date: 3/31/18 | Neonatal Abstinence Syndrome Guidelines (PDF)
Effective Date: 10/30/17 | Total Artificial Heart (PDF)
Effective Date: 12/29/17 |
Cardiac Biomarker Testing (PDF)
Effective Date: 3/30/18 | Neonatal Sepsis Management (PDF)
Effective Date: 7/31/18 | Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Effective Date: 4/30/18 |
Carrier Screening in Pregnancy (PDF)
Effective Date: 5/31/18 | Nerve Blocks for Pain Management (PDF)
Effective Date: 8/31/2018 | Transcatheter Closure of Patent Foramen Ovale (PDF)
Effective Date: 12/29/17 |
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)
Effective Date: 8/31/2018 | NICU Apnea Bradycardia Guidelines (PDF)
Effective Date: 5/31/18 | Trigger Point Injections for Pain Management (PDF)
Effective Date: 8/31/2018 |
Cell-free Fetal DNA Testing (PDF)
Effective Date: 4/30/18 | NICU Discharge Guidelines (PDF)
Effective Date: 9/30/17 | Ultrasound in Pregnancy (PDF)
Effective Date: 6/30/18 |
Clinical Trials (PDF)
Effective Date: 11/30/17 | Non-myeloablative Allogeneic Stem Cell Transplants (PDF)
Effective Date: 2/28/18 | Urinary Incontinence Devices and Treatments (PDF)
Effective Date: 3/31/18 |
Cochlear Implant Replacements (PDF)
Effective Date: 7/31/18 | Obstetrical Home Health Care Programs (PDF)
Effective Date: 1/31/18 | Urodynamic Testing (PDF)
Effective Date: 05-14-21 |
Cosmetic and Reconstructive Surgery (PDF)
Effective Date: 3/31/18 | Optic Nerve Decompression Surgery (PDF)
Effective Date: 9/30/17 | Vagus Nerve Stimulation (PDF)
Effective Date: 10/31/17 |
Dental Anesthesia (PDF)
Effective Date: 4/30/18 | Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 7/31/18 | Ventricular Assist Devices (PDF)
Effective Date: 2/28/18 |
Digital Electroencephalography Spike Analysis (PDF)
Effective Date: 1/31/18 | Pancreas Transplant (PDF)
Effective Date: 1/31/18 | Ventriculectomy and Cardiomyoplasty (PDF)
Effective Date: 2/28/18 |
Disc Decompression Procedures (PDF)
Effective Date: 5/31/18 | Panniculectomy (PDF)
Effective Date: 3/31/18 | Wheelchair Seating (PDF)
Effective Date: 05-14-21 |
Discography (PDF)
Effective Date: 6/30/18 | Pediatric Heart Transplant (PDF)
Effective Date: 1/31/18 | Wireless Motility Capsule (PDF)
Effective Date: 3/31/18 |
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)
Effective Date: 7/31/20 | Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: 5/31/18 | Zika Virus Testing (PDF)
Effective Date: 5/31/18 |
Donor Lymphocyte Infusion (PDF)
Effective Date: 11/30/17 | Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
Effective Date: 10/30/17 | Cardiac Rehabilitation (PDF)
Effective Date: 5/31/2019
|
Durable Medical Equipment (DME) (PDF)
Effective Date: 7/31/18 | Proton and Neutron Beam Therapy (PDF)
Effective Date: 2/28/18 | Video Electroencephalograhic (VEEG) Monitoring (PDF)
Effective Date: 10/31/2019
|
Electric Tumor Treating Fields (PDF)
Effective Date: 3/31/18 | Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Effective Date: 1/1/18
| Antithrombin III (Atryn, Thrombate) (PDF)
Effective Date: 10/31/2019
|
Electroencephalography in the Evaluation of Headache (PDF)
Effective Date: 10/2021 | Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/18
| Implantable Hypoglossal Nerve Stimulation (PDF)
Effective Date: 11/1/2019
|
Endometrial Ablation (PDF)
Effective Date: 7/31/18 | Fluorescein Angiography (PDF)
Effective Date: 1/1/18
| Diagnostic Testing Guidelines: 2019-Novel Coronavirus (PDF)
Effective Date: 3/1/2020
|
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/2019 | Fundus Photography (PDF)
Effective Date: 1/1/18
| Short Inpatient Hospital Stay
Effective Date: 05/01/22
|
Essure Removal (PDF)
Effective Date: 11/30/17 | Gonioscopy (PDF)
Effective Date: 10/1/16
| |
Evoked Potential Testing (PDF)
Effective Date: 05/14/21 | External Ocular Photography (PDF)
Effective Date: 10/1/16
| |
Experimental Technologies (PDF)
Effective Date: 6/30/18 | Visual Field Testing (PDF)
Effective Date: 1/1/18
| |
Facet Joint Interventions for Pain Management (PDF)
Effective Date: 9/14/2018 | Pulmonary Function Testing - CP.MP.242
Last revision: 07/22 | |
Fecal Calprotectin Assay (PDF)
Effective Date: 11/30/17 | BH Treatment Documentation Requirement (PDF) - CP.BH.500 Last Rev. 06/2022 | |
Fecal Incontinence Treatments (PDF)
Effective Date: 12/29/17 | Buckeye’s Substance Use Disorder Treatment Policy
OH.BH.CP.100
March 2023
| |
Ferriscan R2-MRI (PDF)
Effective Date: 11/30/17 | | |
Fertility Preservation (PDF)
Effective Date: 10/30/17 | | |
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
Effective Date: 10/30/17 | | |
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: 12/29/17 | | |
Functional MRI (PDF)
Effective Date: 10/31/17 | | |
Gastric Electrical Stimulation (PDF)
Effective Date: 10/31/17 | | |
Gender Affirming Procedures (PDF)
Effective Date: 11/30/17 | | |
Genetic Testing (PDF)
Effective Date: 4/30/18 | | |
H. Pylori Serology Testing (PDF)
Effective Date: 12/29/17 | | |
Heart-Lung Transplant (PDF)
Effective Date: 4/30/18 | | |
Holter Monitors (PDF)
Effective Date: 6/30/18 | | |
Home Birth (PDF)
Effective Date: 12/29/17 | | |
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)
Effective Date: 12/21/17 | | |
Homocysteine Testing (PDF)
Effective Date: 5/2020 | | |
Hospice Services (PDF)
Effective Date: 1/1/18 | | |
Hyperbaric Oxygen Therapy (PDF)
Effective Date: 2/28/18 | | |
Hyperemesis Gravidarum Treatment (PDF)
Effective Date: 3/30/18 | | |
Hyperhidrosis Treatments (PDF)
Effective Date: 2/28/18 | | |