Coverage Determination Guidelines
Click on the title of the guideline in the alphabetical list below to view/download the guideline.
Administrative Denial (UM-040)
AI-Enabled CT-Based Quantitative Coronary Topography Coronary Plaque Analysis (CDG-060)
Allogenic Hematopoietic Cell Transplantation (CDG-059)
Amniotic and Placental Derived Product Injections and/or Applications (CDG-024)
Autism Spectrum Disorders Diagnosis and Treatment (CDG-042)
B-Type Natriuretic Peptide Testing (CDG-072)
Back Pain Invasive Procedures (CDG- 002)
Biofeedback (CDG-004)
Bisphosphonate Drug Therapy (CDG-007)
Biventricular Pacing (CDG-005)
Bladder Urothelial Tumor Markers (CDG-080)
Botulinum Toxins (CDG-027)
Brachytherapy (CDG-031)
Breast Excision and Mastectomy (CDG-032)
Breast Imaging (CDG-033)
Bronchial Thermoplasty (CDG-035)
Cardiac Catheterization and Coronary Angiography (CDG-036)
Cardiac Radionuclide Imaging (CDG-079)Â
Cardiovascular Stress Testing (CDG-006)
Cataract Surgery (CDG-073)
Cerumen Removal (CDG-081)
Cervical Fusion (CDG-067)
Chemotherapy Drugs and their Adjuncts (CDG-082)
Chiropractic Services (CDG-068)
Coenzyme Q10Â (CDG-087)
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (CDG-070)
Computed Tomographic Angiography of the Chest-Heart and Coronary Arteries (CDG-008)
Computed Tomographic Colonography (CDG-009
Corneal Hysteresis (CDG-061)
Cryoablation (CDG-034)
Cystatin C Measurement (CDG-071)
Debridement Services (CDG-083)
Diagnostic Aerosol or Vapor Inhalation (CDG-97)
Dynamic Spinal Stabilization Devices (CDG-044)
Early Prostate Cancer Detection (CDG_045)
Elective Aorta and Iliac Artery Aneurysm Repair (CDG-038)
Electrocardiographic Monitoring (CDG-015)
Endobronchial Valves for the Treatment of Emphysema (CDG-046)
Endoscopic Treatment of GERDÂ (CDG-062)
Extended Ophthalmoscopy and Fundus Photography (CDG-011)
Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis (CDG-047)
Fecal Incontinence Evaluation and Treatments (CDG-039)
Flow Cytometry (CDG-010)
Fusion Imaging for Cancer and Noncancer (CDG-030)
Gastric Pacing Gastric Electrical Stimulation (CDG-048)
Headache and Occipital Neuralgia Treatments (CDG-049)
Health and Behavioral Assessment Intervention (CDG-084)
High Sensitivity C Reactive Protein (CDG-098)
Home Health Skilled Nursing Services (CDG-078)
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (CDG-053)
I and D of Skin Abscess, Subcutaneous and Accessory Structures (CDG-086)
Implantable Infusion Pump(CDG-085)
Infliximab (CDG-014)
Intensity Modulated Radiation Therapy (CDG 075)
Interspinous Process Decompression(CDG-021)
Ionized Calcium (CDG-096)
Long Term Acute Care Hospitals(CDG-041)
Lumbar Spinal Fusion(CDG-022)
Luteinizing Hormone Releasing Hormone Analogs (CDG-016)
Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing (CDG-066)
Nasal Punctum Nasolacrimal Duct Dilation and Probing with or without Irrigation (CDG-055)
Noncoronary Vascular Stents (CDG-020)
Noninvasive Tests for Hepatic Fibrosis (CDG-043)
Noninvasive Vascular Studies (CDG-025)
Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments (CDG-052)
Ocular Surface Disease Diagnosis and Treatments (CDG-054)
Outpatient Mental Health Services (CDG-076)
Outpatient Physical and Occupational Therapy Services (CDG-029)
Percutaneous Coronary Intervention (CDG-037)
Peripheral Nerve Stimulation (CDG-051)
)Peroral Endoscopic Myotomy (CDG-089
Pulmonary Stress Testing (CDG-065)
Reduction Mammaplasty (CDG-017)
Remote Patient Monitoring and Chronic Care Management (CDG-095)
Removal of Benign Skin Lesions (CDG-028)
Rituximab (CDG-074)
Scanning Computerized Ophthalmic Diagnostic Imaging (CDG-012)
Serum Magnesium (CDG-090)
Special Histochemical and Immunohistochemical Stains (CDG-088)
Stereotactic Radiation Therapy (CDG-018)
Surgical Procedures of the Foot(CDG-040)
Swallowing Studies for Dysphagia (CDG-091)
Temporomandibular Disorders (CDG-056)
Topical Oxygen Therapy (CDG-092)
Transanal Endoscopic Surgery (CDG-069)
Transtelephonic Spirometry (CDG-093)
Transthoracic Echocardiography (CDG-026)
Tumor Markers (CDG-001)
Uterine Fibroid Surgical Treatments (CDG-057)
Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications (CDG-058)
Viscosupplementation (CDG-003)
White Cell Colony Stimulating Factors (CDG-013)
YAG Capsulotomy (CDG-094)
