| SURG.00142 Genicular Procedures for Treatment of Knee Pain | SURG.00142 · Commercial | 7 | Original policy ↗ |
| SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia | SURG.00144 · Commercial | 3 | Original policy ↗ |
| SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) | SURG.00145 · Commercial | 12 | Original policy ↗ |
| SURG.00146 Extracorporeal Carbon Dioxide Removal | SURG.00146 · Commercial | 1 | Original policy ↗ |
| SURG.00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy | SURG.00148 · Commercial | 1 | Original policy ↗ |
| SURG.00149 Percutaneous Ultrasonic Ablation of Soft Tissue | SURG.00149 · Commercial | 2 | Original policy ↗ |
| SURG.00153 Cardiac Contractility Modulation Therapy | SURG.00153 · Commercial | 32 | Original policy ↗ |
| SURG.00155 Cryosurgery of Peripheral Nerves | SURG.00155 · Commercial | 8 | Original policy ↗ |
| SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | SURG.00158 · Commercial | 16 | Original policy ↗ |
| SURG.00159 Focal Laser Ablation for the Treatment of Prostate Cancer | SURG.00159 · Commercial | 1 | Original policy ↗ |
| SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease | SURG.00160 · Commercial | 2 | Original policy ↗ |
| SURG.00161 Nanoparticle-Mediated Thermal Ablation | SURG.00161 · Commercial | 4 | Original policy ↗ |
| SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis | SURG.00162 · Commercial | 4 | Original policy ↗ |
| SURG.00165 Histotripsy | SURG.00165 · Commercial | 5 | Original policy ↗ |
| Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions | LAB.00026 · Commercial | 5 | Original policy ↗ |
| Technology Assisted Surgical Procedures | G-10004 · Effective Sep 1, 2023 · Medicaid · NV | 3 | Original policy ↗ |
| Technology Assisted Surgical Procedures - Professional and Facility | C-21008 · Effective Aug 1, 2023 · Commercial · CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI | 4 | Original policy ↗ |
| THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation | THER-RAD.00012 · Commercial | 3 | Original policy ↗ |
| Three-Dimensional (3D) Radiology Services – Professional and Facility | C-22004 · Effective May 1, 2026 · Commercial · CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI | 2 | Original policy ↗ |
| TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft) | TRANS.00004 · Commercial | 2 | Original policy ↗ |
| TRANS.00009 Lung and Lobar Transplantation | TRANS.00009 · Commercial | 9 | Original policy ↗ |
| TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias | TRANS.00023 · Commercial | 19 | Original policy ↗ |
| TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome | TRANS.00024 · Commercial | 19 | Original policy ↗ |
| TRANS.00026 Heart/Lung Transplantation | TRANS.00026 · Commercial | 4 | Original policy ↗ |
| TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors | TRANS.00027 · Commercial | 19 | Original policy ↗ |
| TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma | TRANS.00028 · Commercial | 19 | Original policy ↗ |
| TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias | TRANS.00029 · Commercial | 26 | Original policy ↗ |
| TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors | TRANS.00030 · Commercial | 19 | Original policy ↗ |
| TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors | TRANS.00031 · Commercial | 19 | Original policy ↗ |
| TRANS.00033 Heart Transplantation | TRANS.00033 · Commercial | 5 | Original policy ↗ |
| TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus | TRANS.00034 · Commercial | 19 | Original policy ↗ |
| TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products | TRANS.00035 · Commercial | 27 | Original policy ↗ |
| TRANS.00037 Uterine Transplantation | TRANS.00037 · Commercial | 7 | Original policy ↗ |
| TRANS.00038 Thymus Tissue Transplantation | TRANS.00038 · Commercial | 3 | Original policy ↗ |
| Transcatheter Mitral, Pulmonary, and Tricuspid Heart Valve Procedures | SURG.00121 · Commercial | 15 | Original policy ↗ |
| Transcranial Magnetic Stimulation (TMS) Request Form - Commercial | Commercial · CO, CT, GA, IN, KY, ME, MO, NH, NV, NY, OH, VA, WI | 2 | Original policy ↗ |
| Transitional Care Management – Professional | C-22002 · Effective Apr 27, 2022 · Commercial · CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI | 2 | Original policy ↗ |
| Transportation Services: Ambulance and Non-Emergent Transport | G-07036 · Effective May 22, 2024 · Medicaid · NV | — | Original policy ↗ |
| Trauma Activation - Facility | C-24003 · Effective Mar 1, 2025 · Commercial · CO, CT, GA, IN, ME, MO, NH, NV, OH, WI | 3 | Original policy ↗ |
| Treatment Rooms - Facility | C-20005 · Effective Jul 1, 2026 · Commercial · CT, GA, IN, KY, ME, MO, NH, NV, OH, WI | 1 | Original policy ↗ |
| Unlisted or Miscellaneous Codes | G-06004 · Effective Nov 4, 2024 · Medicaid · NV | — | Original policy ↗ |
| Upper Extremity Myoelectric Orthoses | OR-PR.00005 · Commercial | 5 | Original policy ↗ |
| Urgent Care Options (Northern Nevada) | Commercial · NV | — | Original policy ↗ |
| Urgent Care Options (Southern Nevada) | Commercial · NV | — | Original policy ↗ |
| Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques | SURG.00077 · Commercial | 4 | Original policy ↗ |
| Vaccinations - Adolescent | Commercial · CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI | — | Original policy ↗ |
| Vaccines for Children (VFC) Program | G-05022 · Effective Nov 4, 2024 · Medicaid · NV | — | Original policy ↗ |
| Vanderbilt ADHD Diagnostic Parent Rating Scale | Commercial · CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI | — | Original policy ↗ |
| Virtual Visits - Professional and Facility | C-08002 · Effective Jul 1, 2024 · Commercial · CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI | 1 | Original policy ↗ |
| What Beneficiary Notice Form to Use | CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI | — | Original policy ↗ |