New Medicare Advantage HMO policy notifications posted October 1, 2014 Below is a listing of the policy notifications available on our website for MedicareAdvantage HMO policies that go into effect January 1, 2015. To view all notifications and policy changes, visit www.amerihealth.com/medpolicy and select Accept and Go to Medical Policy Online. Then select the Medicare Advantage link under “Policy Notifications.” The below policies are listed numerically within the following categories: ●●Administrative ●●Medicine ●●Anesthesia ●●Drugs and Biologics ●●Case Management ●●Radiology ●●Clinical Logic ●●Rehabilitation Services ●●Dental ●●Surgery ●●Durable Medical Equipment (DME) ●●Miscellaneous ●●Pathology and Laboratory

Administrative Policy # Title Policy # Title Intravenous (IV) Administration of Fluids as Obsolete or Unreliable Diagnostic Tests and a Treatment of a Medical Condition or for the MA00.001 MA00.022 Medical Services Preparation of Pharmaceuticals, Biologics, and other Substances MA00.002 Continuous Glucose Monitors MA00.023 Inpatient Hospital Readmission MA00.003 Preventive Care Services Reporting Requirements for Drugs and MA00.024 Routine Costs of Clinical Trials and Coverage of Biologicals MA00.004 Investigational Devices A and B Reporting of Healthcare Common Procedure MA00.025 MA00.005 Experimental/Investigational Services Coding System (HCPCS) C Series Codes Infusion Therapy Services as Performed by MA00.026 Always Bundled Procedure Codes MA00.008 Home Infusion Providers Diagnostic Radiology Services Included in MA00.027 Reporting and Documentation Requirements for Capitation MA00.009 Anesthesia Services Outpatient Short-Term Rehabilitation Services MA00.028 PPO Network Rules for Provision of Specialty Included in Capitation Services for Durable Medical Equipment and MA00.010 Physical Medicine and Rehabilitation Services Laboratory, Radiology, and Physical Medicine Eligible for Reimbursement Above Capitation and Rehabilitative Services to Physical and Occupational Therapy (PT/ MA00.011 Modifier 62: Two Surgeons MA00.029 OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Cast and Splint Applications and Associated Maintenance Organization Point-of-Service MA00.012 Supplies Provided in the Office Setting (HMO-POS) Products MA00.013 Physician Standby Services Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or MA00.030 MA00.014 Modifier 66: Surgical Team Health Maintenance Organization Point-of-Service (HMO-POS) Products Modifiers for Assistant-at-Surgery Services: 80, MA00.015 X-rays Associated with Fractures in the Office 81, 82, and AS MA00.031 Setting MA00.016 Add-on Codes MA00.032 Direct Access Obstetrics/Gynecology (OB/GYN) MA00.017 Medical Team Conferences Services Paid Above Capitation for Health MA00.018 Prolonged Face-to-Face Physician Services MA00.033 Maintenance Organization (HMO) Primary Care Physicians MA00.019 Radiologic Guidance of a Procedure Photography Used for Documentation/Record- MA00.034 STAT Laboratory Tests Performed in the Keeping Purposes Outpatient Hospital Setting for Health MA00.021 MA00.035 Home Visits by a Physician Maintenance Organization (HMO) and Point-of-Service (POS) Products Remote Patient Management: Telemedicine MA00.036 and Telehealth

1 Administrative (continued) Policy # Title Policy # Title Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Billing for Professional Office-Based Services MA03.003 Performed in an Outpatient Office-Based Same Physician on the Day of a Procedure or MA00.037 Setting Located within a Facility or on a Facility Other Service Campus MA03.004 Modifier 51: Multiple Procedures MA00.038 Marijuana for Medical Use MA03.005 Modifier 59: Distinct Procedural Service MA00.039 Never Events and Preventable Adverse Events Modifiers LT/RT: Left Side/Right Side MA03.006 Procedures MA00.040 Facility Reporting of Observation Services Modifier 77: Repeat Procedure by Another National Correct Coding Initiative (NCCI) Code MA03.007 MA00.041 Physician Pair Edits Modifier 78: Unplanned Return to the MA00.042 Humanitarian Use Devices (HUDs) Operating/Procedure Room by the Same MA03.008 Physician Following the Initial Procedure for a New Jersey Health Maintenance Organization Related Procedure During the Postoperative (HMO) and Health Maintenance Organization MA00.043 Period Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances Modifier 24: Unrelated Evaluation and MA03.009 Management Service by the Same Physician Diagnosis Criteria for Reimbursement of MA00.044 during a Postoperative Period Emergency Room Services Reimbursement for Certified Registered Nurse MA03.010 Modifier 57: Decision for Surgery MA00.045 Practitioners (CRNP) Modifiers 26 (Professional Component) and TC MA03.011 (Technical Component) Anesthesia Modifier 79: Unrelated Procedure or Service by MA03.012 the Same Physician During the Postoperative Policy # Title Period Anesthesia Services for a Cancelled or MA01.001 MA03.013 Modifier 51 Exempt Discontinued Procedure MA03.014 Modifier 52 Reduced Services Preoperative Consultations Performed by MA01.002 Providers in Anesthesia Specialties Electrocardiogram (ECG/EKG) Reported with Organ and Tissue Recovery from a Cadaveric Single Photon Emission Computed Tomography MA01.003 MA03.015 Donor and Associated Services (SPECT) for Myocardial Perfusion Imaging (MPI) Continuous Local Delivery of Anesthesia to Insertion or Application of Urinary Catheters MA01.004 Operative Sites Using an Elastomeric Infusion MA03.016 and the Associated Supplies Provided in the Pump Office Setting Multiple Procedure Payment Reduction (MPPR) MA01.005 Modifiers for Shared or Split Surgical Services on Certain Diagnostic Services MA03.017 (Modifiers 54, 55, 56)

Case Management Dental Policy # Title Policy # Title Dental Extractions Prior to Cardiac Surgery, MA02.001 Hospice Care MA04.001 Radiation Therapy, or Transplant Surgery MA02.002 Private Duty Nursing Extraction of Bony Impacted Teeth and MA04.002 MA02.003 Home Health Care Services Exposure of Impacted Teeth

Clinical Logic DME Policy # Title Policy # Title Modifier 76: Repeat Procedure by Same MA05.001 High-Frequency Chest Wall Oscillation Devices MA03.001 Physician MA05.002 Hospital Beds and Accessories MA03.002 Modifier 50: Bilateral Procedure MA05.003 Speech and Non-Speech Generating Devices Pneumatic Compression Therapy Devices for MA05.004 Lymphedema and Chronic Venous Insufficiency

2 DME (continued) Policy # Title Policy # Title Non-Implantable Pelvic Floor Electrical MA05.039 Stimulator MA05.005 Automatic External Defibrillators Food and Drug Administration (FDA) Approval Transcutaneous Electrical Nerve Stimulators MA05.040 MA05.006 of Medical Devices (TENS) and Associated Supplies MA05.041 Blood Pressure Devices for Home Use MA05.007 Nebulizers MA05.042 Pulse Oximetry Device in the Home Setting MA05.008 Negative Pressure Wound Therapy Mechanical Stretching Devices for the MA05.043 MA05.009 Cervical Traction Devices for In-home Use Treatment of Stiffness or Contractures MA05.010 Ankle-Foot/-Ankle-Foot Orthoses MA05.044 Durable Medical Equipment (DME) MA05.011 Seat Lift Mechanisms MA05.045 Compression Garments MA05.012 Orthopedic Footwear MA05.046 Wheelchair Options/Accessories Treatment of Obstructive Sleep Apnea (OSA) MA05.013 Knee Braces MA05.047 and Primary Snoring in Adults MA05.014 Ostomy Supplies MA05.048 Bladder Stimulators (Pacemakers) MA05.015 Home Blood Glucose Monitors and Supplies MA05.049 Electronic Speech Aids MA05.016 Home Prothrombin Time Monitoring MA05.050 Eye Prosthesis MA05.017 Home Oxygen Therapy MA05.052 Canes and Crutches Osteogenic Stimulators (i.e., Electrical Growth Stimulation and Low-Intensity MA05.053 Implantable and External Infusion Pumps MA05.018 Ultrasound Accelerated Fracture Healing MA05.054 Urological Supplies System) Continuous Passive Motion (CPM) Devices for MA05.055 Standing Frames MA05.019 Home Use Noninvasive Respiratory Assist Devices MA05.020 Therapeutic Shoes MA05.056 (RADs): Continuous Positive Airway Pressure (CPAP) and Bi-Level Devices (BiPAP) MA05.021 Injectable Dermal Fillers MA05.057 Upper-Limb Prostheses Home-Use Light Box for the Treatment of MA05.022 Neuromuscular Electrical Stimulators (NMES) Seasonal Affective Disorder (SAD) MA05.058 and Functional Electrical Stimulators (FES) MA05.023 Wheelchair Cushions and Seating MA05.059 Electrical Continence Aid MA05.024 Lower Limb Prostheses Home Use of Interferential and Sequential MA05.061 MA05.025 Pressure Reducing Support Surfaces Stimulation Devices Repair and Replacement of Durable Medical MA05.062 MA05.026 Manual Wheelchair Bases Equipment (DME) Durable Medical Equipment (DME) Not Subject Repair or Replacement of an External MA05.028 MA05.063 to a Rental to Purchase Maximum Prosthetic Device MA05.029 Heating Pads and Heat Lamps Percutaneous Electrical Nerve Stimulation MA05.064 (PENS) and Percutaneous Neuromodulation MA05.030 Spinal Orthoses Therapy (PNT) MA05.031 Patient Lifts Pathology and Laboratory MA05.032 Power Mobility Devices Policy # Title MA05.033 External Breast Prosthesis MA06.001 Apheresis Therapy MA05.034 Tracheostomy Care Supplies MA06.002 In Vitro Allergy Testing MA05.035 Cold Therapy Devices MA06.004 In Vivo Allergy Sensitivity Testing MA05.036 Commodes Lyme Disease: Diagnosis and Intravenous (IV) MA06.006 MA05.037 Walkers Antibiotic Treatment

3 Pathology and Laboratory (continued) Policy # Title Policy # Title Platelet-Rich Plasma (PRPs) for Chronic MA07.008 Non-Healing Wounds and Stem-Cell Therapy Loss-of-Heterozygosity-Based Topographic MA06.007 for Orthopedic Applications Genotyping with PathFinderTG® Routine Foot Care For Certain Medical Pharmacogenetic Testing to Determine Drug MA07.009 MA06.008 Conditions Sensitivity Computer Analysis and Generation of MA07.010 Biofeedback Therapy MA06.009 Automated Data in Conjunction with Diagnostic MA07.011 Topical Oxygenation Studies Genetic Testing for Inherited Breast Cancer MA07.012 External Counterpulsation (ECP) MA06.010 1 (BRCA1) and Breast Cancer 2 (BRCA2) Electrical Stimulation and Electromagnetic MA07.013 Mutations Stimulation for the Treatment of Wounds Human Immunodeficiency Virus (HIV) MA06.011 MA07.014 Magnetic Pelvic Floor Stimulation (MPFS) Genotyping and Phenotyping Genetic Testing for Inherited Susceptibility to Evaluation and Management (E&M) of Diabetic Colon Cancer and Microsatellite Instability MA07.015 Peripheral Neuropathy with Loss of Protective MA06.012 Testing (Familial Adenomatous Polyposis and Sensation (LOPS) Lynch Syndrome) MA07.016 Intravenous Chelation Therapy Serodiagnosis of Inflammatory Bowel Hyperthermic Intraperitoneal Chemotherapy MA06.013 Disease (IBD) and the Prometheus® IBD sgi MA07.017 (HIPEC) Diagnostic™ Test Anorectal Manometry, Electromyography Pharmacogenetics and Metabolite Monitoring (EMG) of Anorectal or Urethral Sphincters; MA06.014 Using Azathioprine (AZA)/6-Mercaptopurine MA07.018 Biofeedback Training for Perineal Muscles and (6-MP) Therapy Anorectal or Urethral Sphincters AlloMap™ Molecular Expression Testing for MA06.015 Reimbursement for the Administration of Heart Transplant Rejection MA07.019 Immunizations Heartsbreath Test for Heart Transplant MA06.016 Whole-body Integumentary Photography and Rejection MA07.020 Dermatoscopy MA06.017 Molecular Diagnostics MA07.021 Partial Coherence Interferometry MA06.018 Immune Cell Function Assay MA07.022 Wireless Capsule Endoscopy Measurement of Serum Antibodies to and Medical and Surgical Treatment of MA06.019 Measurement of Serum Levels of Infliximab and MA07.024 Temporomandibular Joint Disorder Adalimumab Intrauterine Systems (IUSs) (e.g., Mirena®, Autologous Blood Services (Collection, Storage, MA07.025 MA06.020 Skyla®) Transfusion, and Perioperative Salvage) In Vitro Chemosensitivity and Chemoresistance MA07.029 Refractive Lenses MA06.021 Assays Photodynamic Therapy (PDT) using Porfimer MA07.030 ® MA06.022 Biomarkers for Oncology Sodium (Photofrin ) Nerve Conduction Studies (NCS) and Related MA07.033 MA06.023 Nerve Fiber Density Testing Electrodiagnostic Studies MA06.030 Circulating Tumor Cell (CTC) Assay Repetitive Transcranial Magnetic Stimulation MA07.035 (rTMS) Medicine MA07.036 Cold Laser Therapy Policy # Title MA07.038 Neuropsychological Evaluation/Testing Magnetoencephalography (MEG) with Magnetic MA07.001 Hyperbaric Oxygen Therapy MA07.039 Source Imaging (MSI) Ultraviolet Light Therapy for the Treatment of MA07.002 Transcatheter Arterial Chemoembolization Dermatological Conditions MA07.040 (TACE) of Hepatic Malignancies Photodynamic Therapy Using Verteporfin MA07.003 ® Drug-Eluting Beads and Bland Embolization for (Visudyne ) MA07.041 the Treatment of Hepatic Malignancies Scanning Computerized Ophthalmic Diagnostic MA07.004 Imaging (SCODI) MA07.042 Complete Decongestive Therapy (CDT) MA07.005 Ambulatory Blood Pressure Monitoring (ABPM) MA07.043 Smell and Taste Dysfunction Testing

4 Medicine (continued) Policy # Title Policy # Title Treatment of Pulmonary Artery Hypertension MA08.016 with Intravenous, Subcutaneous, and Inhaled Measurement of Exhaled Nitric Oxide and Pharmacologic Agents Intended for Home Use Breath Condensate in the Diagnosis and MA07.044 Management of Asthma and Other Respiratory MA08.017 Botulinum Toxin Agents Disorders MA08.018 Trastuzumab (Herceptin®) MA07.045 Microvolt T-Wave Alternans (MTWA) MA08.019 Infliximab (Remicade®) MA07.046 Corneal Pachymetry Using Ultrasound MA08.021 Dofetilide (Tikosyn®) Use in the Inpatient Setting Pain Management of Peripheral Nerves by MA07.047 Injection MA08.022 Rituximab (Rituxan®) MA07.048 Instrument-Based Vision Screening Enzyme Replacement for the Treatment of MA08.023 Gaucher's Disease MA07.049 Implantable Cardiac Loop Monitor MA08.025 Omalizumab (Xolair®) Electromyography (EMG) Studies: Needle MA07.050 EMG, Surface EMG (SEMG) Complex Regional Pain Syndrome (CRPS) MA08.026 Parenteral Treatments MA07.051 Intraoperative Neurophysiological Testing MA08.027 Risperidone (Risperdal® Consta®) Injection Bioimpedance for the Detection of MA07.052 Lymphedema Abatacept (Orencia®) for Injection for MA08.028 Intravenous Use MA07.055 Allergy Immunotherapy MA08.029 Natalizumab (Tysabri®) Photodynamic Therapy (PDT) Using Levulan® ® MA07.056 Kerastick (Aminolevulinic Acid HCl [ALA]) or MA08.031 Cetuximab (Erbitux®) Metvixia® (Methyl Aminolevulinate [MAL]) ® Cardiac Event Detection Monitoring (External MA08.033 Agalsidase beta (Fabrazyme ) MA07.057 Loop Monitoring) MA08.034 Laronidase (Aldurazyme®) MA07.058 Sleep Disorder Testing MA08.035 Idursulfase (Elaprase™) MA07.060 Oral and Maxillofacial Prosthesis Alglucosidase Alfas, rhGAA (Myozyme®, MA08.036 ® MA07.069 Real-Time, Outpatient Cardiac Telemetry Lumizyme ) MA08.037 Bortezomib (Velcade®) Drugs and Biologics MA08.038 Oxaliplatin (Eloxatin®) Policy # Title MA08.039 Plerixafor Injection (Mozobil™) MA08.001 Vedolizumab (Entyvio®) MA08.041 Bendamustine Hydrochloride (Treanda®) Nesiritide (Natrecor®) for Treatment of Heart MA08.002 Ustekinumab (Stelara™) for Subcutaneous Failure Patients MA08.042 Injection MA08.003 Enteral Nutritional Therapy MA08.043 Pralatrexate (Folotyn®) for Injection MA08.004 Coagulation Factors for Hemophilia MA08.044 Eculizumab (Soliris®) MA08.005 Elosulfase alfa (Vimizim™) MA08.045 Tocilizumab (Actemra®) for Intravenous Infusion MA08.007 Medicare Part B vs. Part D Crossover Drugs MA08.046 Ecallantide (Kalbitor®)

Total Parenteral Nutrition (TPN), Intradialytic ® MA08.008 Nutrition (IDPN) and Intraperitoneal Nutrition MA08.047 Pemetrexed (Alimta ) (IPN) MA08.048 Ofatumumab (Arzerra™) Immune Globulin: Intravenous (IVIG), MA08.009 Subcutaneous (SCIG) Paclitaxel Protein-bound Particles for Injectable MA08.049 Suspension (Albumin-bound)/(Abraxane® for MA08.011 Erythropoiesis Stimulating Agents (ESAs) Injectable Suspension) Off-label Coverage for Prescription Drugs Alpha 1-Proteinase Inhibitor Therapy (e.g., MA08.012 ® and/or Biologics MA08.050 Prolastin-C , Aralast™, Aralast NP™, Glassia™, Zemaira™) Radioimmunotherapy with Ibritumomab MA08.014 ® C1 Esterase Inhibitors: Cinryze®, Berinert®, and Tiuxetan (Zevalin ) MA08.051 Ruconest®

5 Drugs and Biologics (continued) Policy # Title Policy # Title Electron Beam Computed Tomography (EBCT) MA09.011 for Screening Evaluations MA08.052 Denosumab (Prolia™, Xgeva™) Full-Body Computerized Tomography (CT) MA09.012 MA08.053 Personalized Vaccines (e.g., Provenge®) Scan Screening

® Screening for Vertebral Fracture with MA08.054 Cabazitaxel (Jevtana ) MA09.013 Dual-Energy X-ray Absorptiometry (DEXA/DXA) ® MA08.055 Romidepsin (Istodax ) Computer Aided Detection (CAD) System for MA09.014 use with Chest Radiographs MA08.056 Eribulin Mesylate (Halaven™) MA09.015 Positron Emission Mammography (PEM) MA08.057 Belimumab (Benlysta®) MA09.016 Digital Breast Tomosynthesis MA08.059 Ipilimumab (Yervoy®) MA09.017 Brachytherapy MA08.060 Pegloticase (Krystexxa®) Radioembolization for Primary and Metastatic ® MA09.018 MA08.061 Belatacept (Nulojix ) Tumors of the Liver MA08.062 Carfilzomib (Kyprolis™) Magnetic Resonance Imaging (MRI) for MA09.019 Monitoring the Integrity of Silicone-Gel-Filled MA08.063 Pertuzumab (Perjeta®) Breast Implants in Asymptomatic Individuals MA08.064 Omacetaxine Mepesuccinate (Synribo®) Rehabilitation Services MA08.065 Octreotide Acetate (Sandostatin® LAR Depot) Policy # Title MA08.066 Ado-Trastuzumab Emtansine (Kadcyla®) MA10.001 Pulmonary Rehabilitation Services Repository Corticotropin (H.P. Acthar® Gel MA08.067 Cardiac Rehabilitation (CR) and Intensive Injection) MA10.002 Cardiac Rehabilitation (ICR) Programs MA08.068 Brentuximab Vedotin (Adcetris®) Physical Medicine & Rehabilitation Services: MA08.069 Radium Ra 223 dichloride (Xofigo®) Injection MA10.003 Physical Therapy (PT) and Occupational Therapy (OT) Golimumab (Simponi® Aria™) Intravenous (IV) MA08.070 Injection MA10.004 Chiropractic Services MA08.071 Galsulfase (Naglazyme®) MA10.005 Day Rehabilitation MA08.072 Bevacizumab (Avastin®) MA10.007 Speech Therapy Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., MA08.073 Surgery ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®]) Policy # Title Treatment of Varicose Veins of the Lower MA11.001 Radiology Extremities and Perforator Vein Incompetence Policy # Title MA11.002 Hematopoietic Stem Cell Transplantation MA09.001 Intensity Modulated Radiation Therapy (IMRT) MA11.003 Lung Volume Reduction Surgery (LVRS) MA09.002 High-Technology Radiology Services Surgical and Minimally Invasive Treatments MA11.004 for Urinary Outlet Obstruction due to Benign MA09.004 Echocardiography Contrast Agents Prostatic Hyperplasia (BPH) MA09.005 High Osmolar Contrast Agents MA11.005 Deep Brain Stimulation (DBS) MA09.006 Therapeutic Radiology Port Films MA11.006 Bronchial Thermoplasty MA09.007 Proton Beam Therapy MA11.007 Islet Cell Transplantation MA09.008 Low Osmolar Contrast Agents MA11.008 Refractive Keratoplasty Diagnostic and Therapeutic MA11.010 Abortion MA09.009 Radiopharmaceutical Agents Artificial Hearts and Ventricular Assist Devices MA11.011 Magnetic Resonance Imaging (MRI) Contrast (VADs) MA09.010 Agents

6 Surgery (continued) Policy # Title Policy # Title MA11.045 Uterine Artery Embolization Endovascular Grafts for Abdominal Aortic MA11.046 Hair Transplants and Cranial Prostheses (Wigs) MA11.012 Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms Blepharoplasty, Repair of Blepharoptosis, Debridement of Mycotic and Symptomatic MA11.047 Repair of Brow Ptosis, and Canthoplasty/ MA11.014 Non-Mycotic Hypertrophic Nails Canthopexy Lumbar Interspinous Process Decompression MA11.048 MA11.015 Wound Care: Bioengineered Skin Substitutes System MA11.016 Prostate Mapping Biopsy Bone-Anchored (Osseointegrated) Hearing Aids MA11.049 and Implantable Middle Ear Hearing Aids MA11.017 Trigger Point Injections Treatment of Medical and Surgical MA11.050 MA11.018 Mohs' Micrographic Surgery (MMS) Complications Treatment of Obesity and Bariatric Surgery for MA11.019 Vagus Nerve Stimulation (VNS) MA11.051 Treatment of Morbid Obesity MA11.021 Non-Surgical Spinal Decompression Therapy Radiofrequency Ablation and Cryosurgical MA11.052 Ablation of Lung Tumors MA11.022 Cryosurgery of the Prostate MA11.053 Sterilization Hyaluronan Acid Therapies for of MA11.023 the Knee MA11.054 Cataract Surgery Percutaneous Vertebroplasty and Percutaneous Procedures for the Treatment of MA11.024 MA11.055 Gastroesophageal Reflux Disease (GERD) Percutaneous Intradiscal Annuloplasty (IDET/ MA11.025 Percutaneous Transluminal Angioplasty (PTA) PIRFT) MA11.056 and Extracranial (EC) and Intracranial (IC) Epidural, Paravertebral Facet, and Sacroiliac Arterial Bypass Surgery MA11.026 Joint Injections for Spinal Pain Management MA11.057 Robotic-Assisted Surgery Transcatheter Aortic Valve Replacement (TAVR) MA11.027 and Transcatheter Mitral Valve Repair (TMVR) MA11.058 Otoplasty Sacral Nerve Stimulation (SNS) and Posterior Arthroscopic Lavage and Arthroscopic MA11.059 MA11.028 Tibial Nerve Stimulation (PTNS) for the Control Debridement for the Osteoarthritic Knee of Incontinence MA11.060 Catheter Ablation of Cardiac Arrhythmias MA11.030 Reconstructive Breast Surgery Transcoronary Ablation of Septal Hypertrophy Spinal Cord Stimulation (Dorsal Column MA11.061 MA11.031 (TASH) Stimulation) Endovascular Stent-Graft Repair of Thoracic MA11.062 MA11.032 Multiple Surgical Reduction Guidelines Aortic Aneurysms and Nonaneurysmal Lesions MA11.033 Solid Organ Transplants MA11.063 Photocoagulation of Macular Drusen MA11.034 Collagen Meniscus Implant Implantable Miniature Telescope (IMT) for the MA11.064 Treatment of End-Stage Age-Related Macular MA11.035 Infrared Photocoagulation (IRC) of Hemorrhoids Degeneration (AMD) MA11.036 Surgical Treatment of Nails MA11.065 Endometrial Ablation Use of an Operating Microscope During a Ovarian and Internal Iliac Vein Embolization as MA11.037 MA11.066 Surgical Procedure Treatment for Pelvic Congestion Syndrome Radiofrequency Micro-remodeling (by MA11.067 Labiaplasty MA11.038 transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence MA11.068 Sentinel Lymph Node Biopsy MA11.039 Cochlear Implantation MA11.069 Reduction Mammoplasty Transcatheter Closure of Cardiac Septal MA11.070 Lipectomy and Liposuction MA11.040 Defects Selective Photothermolysis Using Pulsed-Dye MA11.071 MA11.042 Revision of a Previous Cosmetic Procedure Lasers (PDL) Reimbursement for a Presbyopia- or MA11.072 Application and Removal of Tattoos MA11.043 Astigmatism-Correcting Intraocular Lens MA11.073 Abdominoplasty and/or Panniculectomy MA11.044 Artificial Intervertebral Disc Insertion

7 Surgery (continued) Policy # Title Policy # Title MA11.104 Lacrimal Punctum Plugs MA11.074 Excision of Redundant Skin Aqueous Shunts, Viscocanalostomy, and MA11.105 Canaloplasty for the Treatment of Glaucoma Rhytidectomy and/or Cervicoplasty With or MA11.075 Without Liposuction and/or Platysmaplasty Miscellaneous MA11.076 Removal of Breast Implants Policy # Title MA11.077 Prophylactic Mastectomy Alternative Therapies and Complementary MA12.001 MA11.078 Scar Revision Medicine Evaluation and Treatment of Erectile MA11.079 MA12.002 Nonemergency Ambulance Transport Dysfunction (ED) MA12.007 Air or Sea Ambulance MA11.080 Mentoplasty or Genioplasty MA11.081 Meniscal Allograft Transplantation Autologous Chondrocyte Implantation (ACI)/ MA11.082 Carticel® and Other Cell-based Treatments of Focal Articular Lesions MA11.083 Osteochondral Autograft Transplantation (OAT) MA11.084 Procedure MA11.085 Arthroscopic Electrothermal Joint Repair MA11.086 Osteochondral Allograft Transplantation Extracorporeal Shock Wave Therapy (ESWT) MA11.087 for Musculoskeletal Conditions Computer-Assisted Musculoskeletal Surgical MA11.088 Navigational Orthopedic Procedure MA11.089 Surgical Treatment of Femoroacetabular MA11.090 Impingement MA11.091 Manipulation Under Anesthesia MA11.092 Total Ankle /Replacement MA11.093 Surgical Treatments of Athletic Pubalgia Treatment for Hyperhidrosis MA11.094 (Nonpharmacologic) MA11.095 Lysis of Epidural Adhesions MA11.096 Percutaneous Percutaneous Image-Guided Lumbar MA11.097 Decompression (PILD) for Spinal Stenosis MA11.098 Migraine Deactivation Surgery MA11.099 Septoplasty, Rhinoplasty, and Septorhinoplasty Balloon Catheter Dilation of Sinus Ostia for MA11.100 Treatment of Chronic Rhinosinusitis MA11.101 Nucleoplasty Denervation of the Spinal Nerves for Chronic MA11.102 Facet Pain MA11.103 Chemical Peels

8