BlueCross BlueShield of Tennessee Medical Policy Manual

Musculoskeletal

• Artificial Intervertebral Disc

• Autologous Chondrocyte Implantation (ACI)

• Automated Percutaneous and Endoscopic Discectomy

• Axial Lumbosacral Interbody Fusion

• Cervical Traction Devices for Home Use

• Computer Assisted Surgical Navigation for Orthopedic Procedures

• Continuous Passive Motion (CPM) Device in the Home Setting

• Diagnosis and Treatment of Sacroiliac Joint Pain

• Dynamic Spinal Visualization and Vertebral Motion Analysis

• Electrical and Electromagnetic Stimulation for the Treatment of Arthritis

• Epidural Steroid Injections for Treatment of  Back Pain

• Facet Arthroplasty

• Facet Joint Injections

• Facet Joint Neurotomy

• Genetic Testing for Facioscapulohumeral Muscular Dystrophy

• Genetic Testing for Mitochondrial Disorders

• Hand and/or Face Transplantation (Composite Tissue Allotransplantation)

• Image-Guided Minimally Invasive Decompression for Spinal Stenosis

• Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers); Interspinous Fixation (Fusion) Devices

• Intervertebral Disc Decompression using Radiofrequency Coblation (Nucleoplasty) or Laser Energy (Laser Discectomy)

• Intradiscal Annuloplasty and Intraosseous Radiofrequency Ablation for Treatment of Back Pain

• Kinesio Taping

• Lysis of Epidural Adhesions

• Manipulation Under Anesthesia (MUA) of the Musculoskeletal System

• Mechanized Axial Spinal Distraction Therapy Devices

• Meniscal Allografts and Synthetic Meniscus Implants

• Mentoplasty (Chin Augmentation, Genioplasty)

• Microprocessor-Controlled Prostheses for the Lower Limb

• Multi-biomarker Testing for Rheumatoid Arthritis

• Orthognathic Surgery

• Orthopedic Applications of Stem Cell Therapy

• Osteochondral Allografting

• Osteochondral Autografting (OCG)

• Percutaneous Sacroplasty

• Percutaneous Vertebroplasty, Kyphoplasty, and Mechanical Vertebral Augmentation

• Piezoelectric Sensor Analysis and Oscillating Force Delivered Vertebral Adjustment in the Evaluation and Treatment of the Spinal Column

• Powered Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities

• Prolotherapy for Musculoskeletal Disorders

• Spinal Unloading Devices for the Treatment of Low Back Pain

• Subtalar Arthroereisis

• Surgical Treatment of Femoroacetabular Impingement

• Total Ankle Replacement

• Treatments for Athletic Groin Pain

• Trigger Point Injections

• Upper Limb Myoelectric Orthosis

• Vertebral Fracture Assessment with Densitometry

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