February 1, 2026 Prioritized List of Health Services
CPT codes, descriptions and other data only are copyright 2025 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren't assigned by the AMA, aren't part of CPT, and the AMA isn't recommending their use. The AMA doesn't directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
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 (Code Pairings)
STATEMENT OF INTENT 1: PALLIATIVE CARE
It is the intent of the Commission that palliative care services are covered for patients with a life-threatening or serious progressive illness to alleviate symptoms and improve quality of life.
Palliative care services should include culturally appropriate discussions and medical decision making aligned with patient's personal goals of therapy, assessment of symptom burden, assistance with advance care planning, care coordination, emotional, psychosocial and spiritual support for patients and their families. Palliative care services may be provided concurrently with life prolonging/curative treatments.
Some examples of services associated with an encounter for palliative care (ICD-10 Z51.5) that should be available to patients without regard to Prioritized List line placement: 
A) Inpatient palliative care consultations 
1) Hospital Care E&M (CPT *99218-99233)
B) Outpatient palliative care consultations provided in either the office or home setting 
1) E&M Services (CPT *99201-99215)
2) Transitional Care Management Services (CPT *99495-6)
3) Advance Care Planning (CPT *99497-8)
4) Chronic Care Management (CPT *99487-99490)
C) Psychological support and grief counseling (CPT *99201-99215)
D) Medical equipment and supplies for the management of symptomatic complications or support activities of daily living
E) Medications or acupuncture to reduce pain and symptom burden
F) Surgical procedures or therapeutic interventions (for example, palliative radiation therapy) to relieve pain or symptom burden
G) Biofeedback (CPT *90875, 90876, 90901) for treatment of cancer pain
Other services associated with palliative care include:
A) Social Work
B) Clinical Chaplain/ Spiritual Care
C) Care Coordination
STATEMENT OF INTENT 1: PALLIATIVE CARE (CONT'D)
It is NOT the intent of the Commission that coverage for palliative care encompasses those treatments that seek to prolong life despite substantial burdens of treatment and limited chance of benefit. See Guideline Note 12 PATIENT-CENTERED CARE OF ADVANCED CANCER.
STATEMENT OF INTENT 2: DEATH WITH DIGNITY ACT
It is the intent of the Commission that services under ORS 127.800-127.897 (Oregon Death with Dignity Act) be covered for those that wish to avail themselves to those services. Such services include but are not limited to attending physician visits, consulting physician confirmation, mental health evaluation and counseling, and prescription medications.
STATEMENT OF INTENT 3: LOWER PRIORITY SERVICES
It is the intent of the Commission that therapies that exhibit one or more of the following characteristics generally be given low priority on the Prioritized List:
A) Marginal or clinically unimportant benefit
B) Unproven/no benefit
C) Harms outweigh benefits
D) Very high cost in which the cost does not justify the benefit
E) Significantly greater cost compared to alternate therapies when both have similar benefit 
F) Significant budget impact that could affect the overall Prioritized List funding level
Where possible, the Commission prioritizes pairings of condition and treatment codes to reflect this lower priority, or simply does not pair a procedure code with one or more conditions if it exhibits one of these characteristics. This is, however, impractical in several circumstances:
A) For diagnostic services appropriate for billing with a variety of diagnoses, including diagnoses representing signs and symptoms as well as diagnoses which otherwise appear above the funding line
B) For ancillary services such as prescription drugs, supplies, physician-administered drugs or durable medical equipment and not identified by a CPT or HCPCS code appropriate for placement on the Prioritized List
STATEMENT OF INTENT 3: LOWER PRIORITY SERVICES (CONT'D)
C) For procedure codes not appropriate for placement in the funded region of the list but which may be billed with many possible diagnoses, some of which are above the funding line while others may be below the funding line
In these circumstances, the HERC identifies the services in Excluded Services Guideline 1 or Excluded Services Guideline 2 in order to make its intent transparent.
STATEMENT OF INTENT 4: ROLE OF THE PRIORITIZED LIST IN COVERAGE
The Commission makes its prioritization decisions based on the best available published evidence about treatments for each condition. The Prioritized List prioritizes health services according to their importance for the population served and the legislature determines where to place the funding line on the Prioritized List.
The Commission recognizes that a condition and treatment pairing above the funding line does not necessarily mean that the service will be covered by the Oregon Health Plan (OHP).  There may be other restrictions that apply, such as the service not being medically necessary or appropriate for an individual member. Likewise, the absence of a treatment and condition pairing above the funding line is not meant to be an absolute exclusion from coverage. Coverage may still be authorized under applicable federal and state laws, and Oregon's Medicaid State Plan and Waiver for an individual member.  For example, OAR 410-141-3820 (Oregon Health Plan Benefit Package of Covered Services) includes services such as, but not limited to, the following:
* Diagnostic services, subject to the List's diagnostic guideline notes when applicable;
* Ancillary services (such as hospitalization, durable medical equipment, certain medications and anesthesia) provided for conditions appearing above the funding line, subject to the List's ancillary guideline notes when applicable; and
* Services paired with (or ancillary to) an unfunded condition which is causing or exacerbating a funded condition, the treatments for the funded condition are not working or contraindicated, and treatment of the unfunded condition would improve the outcome of treating the funded condition (the "Comorbidity Rule" OAR 410-141-3820(10))
STATEMENT OF INTENT 4: ROLE OF THE PRIORITIZED LIST IN COVERAGE (CONT'D)
* Services that are determined to be medically necessary and medically appropriate for an OHP member under the age of 21; coverage of these services is required by federal regulation under the Early and Periodic Screening, Diagnosis and Treatment program (EPSDT).
* Services paired with (or ancillary to) an unfunded condition (or otherwise not consistent with the funded region of the List) which, based on the child's individual circumstances, adversely affects the child's ability to grow, develop, or participate in school only when providing the unfunded service would improve the child's ability to grow, develop or participate in school.
The Prioritized List must be used in conjunction with applicable OHP provisions found in federal and state laws, the State Plan and Waiver in coverage determination.
STATEMENT OF INTENT 5: TREATMENT OF CHRONIC PAIN
It is the intent of the Commission that covered chronic pain conditions be treated in a multidisciplinary fashion, with a focus on active therapies, improving function, and demedicalizing the condition.  Care should include education on sleep, nutrition, stress reduction, mood, exercise, and knowledge of pain. All providers seeing chronic pain patients should be trained in pain science (e.g. a contemporary understanding of the central and peripheral nervous system in chronic pain), motivational interviewing, culturally sensitive care, and trauma-informed care.  Care should be provided as outlined in the Oregon Pain Management Commission pain management module: https://www.oregon.gov/oha/HPA/DSI-PMC/Pages/module.aspx.
STATEMENT OF INTENT 6: TELEPHONIC SERVICES DURING AN OUTBREAK OR EPIDEMIC
During an outbreak or epidemic of an infectious disease, reducing administrative barriers (e.g. increasing reimbursement rates) for telephonic evaluation and management services (CPT *99441-99443) and assessment and management services (CPT *98966-98968) is appropriate to ensure access to care while avoiding and preventing unnecessary potential infectious exposure.
STATEMENT OF INTENT 7: PUBLIC HEALTH EMERGENCIES
It is the intent of the Commission that if the state Public Health Director determines that there exists a disease outbreak, epidemic or other condition of public health importance in a geographic area of this state or statewide, under ORS 743A.264, then all necessary antitoxins, serums, vaccines, immunizing agents, antibiotics, antidotes and other pharmaceutical agents, medical supplies or other prophylactic measures approved or with emergency use authorization by the United States Food and Drug Administration that the Director deems necessary to prevent the spread of the disease, epidemic or other condition of public health importance should be covered.
STATEMENT OF INTENT 8: SMOKING CESSATION AND ELECTIVE SURGICAL PROCEDURES
Tobacco smoking has been shown to increase the risk of surgical complications. It is the intent of the Commission that current tobacco smokers should be given access to appropriate smoking cessation therapy prior to elective surgical procedures.  Pharmacotherapy (including varenicline, bupropion and all five FDA-approved forms of nicotine-replacement therapy) and behavioral counseling are included on Line 5 TOBACCO DEPENDENCE.
It is the intent of the Commission that patients undergoing spinal fusion procedures be strongly encouraged to abstain from all tobacco products for 6 months after surgery due to evidence of harms.




PRACTICE GUIDELINES
GUIDELINE NOTES FOR ANCILLARY, DIAGNOSTIC AND EXCLUDED SERVICES
NOT APPEARING ON THE FEBRUARY 1, 2026 LINES OF THE PRIORITIZED LIST 
OF HEALTH SERVICES


	
ANCILLARY GUIDELINE A1, NERVE BLOCKS
The Health Evidence Review Commission intends that single injection and continuous nerve blocks (CPT *64400-64450, 64461-64463, 64466-64469, 64473-64474, and 64505-64530) should be covered services if they are required for successful completion of perioperative pain control for, or post-operative recovery from a covered operative procedure when the diagnosis requiring the operative procedure is also covered. Additionally, nerve blocks, are covered services for patients hospitalized with trauma, cancer, or intractable pain conditions, if the underlying condition is a covered diagnosis.
Paracervical and pudendal nerve blocks (CPT *64430 and 64435) are also covered for any covered inpatient or outpatient gynecological or obstetrical procedure.
ANCILLARY GUIDELINE A2, SELF-MONITORING OF BLOOD GLUCOSE IN DIABETES
For patients with type 1 diabetes and those with type 2 diabetes using multiple daily insulin injections, home blood glucose monitors and related diabetic supplies are covered.
For patients with type 2 diabetes not requiring multiple daily insulin injections, 50 test strips and related supplies are covered at the time of diagnosis. For those who require diabetic medication that may result in hypoglycemia, up to 50 test strips per 90 days are covered. If there is an acute change in glycemic control or active diabetic medication adjustment, an additional 50 strips are covered.
All diabetic patients who are prescribed diabetic test strips should have a structured education and feedback program for self-monitoring of blood glucose.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
ANCILLARY GUIDELINE A3, IVC FILTERS FOR TRAUMA
It is the intent of the Commission that inferior vena cava (IVC) filter placement (CPT *37191) and subsequent repositioning and removal (CPT *37192, 37193) are covered when medically indicated for hospitalized patients with severe trauma resulting in prolonged hospitalization.
ANCILLARY GUIDELINE A3, IVC FILTERS FOR TRAUMA (CONT'D)
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
ANCILLARY GUIDELINE A4, HOME BLOOD PRESSURE MONITORS
Home blood pressure monitors (HCPCS A4660, A4663, A4670) are covered for diagnosing and monitoring hypertension, including hypertensive diseases of pregnancy, and related cardiac conditions. Automated arm (non-wrist) monitors are preferred as first-line devices. HERC prefers devices included on the US Blood Pressure Validated Device Listing (https://www.validatebp.org/devices retrieved on 11/14/2024) when possible.
ANCILLARY GUIDELINE A5, TELEHEALTH, TELECONSULTATIONS AND ONLINE/TELEPHONIC SERVICES
Telehealth services include a variety of health services provided by synchronous or asynchronous electronic communications, including secure electronic health portal, audio, or audio and video and clinician-to-clinician virtual consultations. 
Criteria for coverage
The clinical value of the telehealth service delivered must reasonably approximate the clinical value of the equivalent services delivered in-person.
Coverage of telehealth services requires the same level of documentation, medical necessity, and coverage determinations as in-person visits. 
Examples of covered telephone or online services include but are not limited to: 
A) Extended counseling when person-to-person contact would involve an unwise delay or exposure to infectious disease.
B) Treatment of relapses that require significant investment of provider time and judgment. 
C) Counseling and education for patients with complex chronic conditions.
Examples of non-covered telehealth services include but are not limited to: 
A) Prescription renewal. 
ANCILLARY GUIDELINE A5, TELEHEALTH, TELECONSULTATIONS AND ONLINE/TELEPHONIC SERVICES (CONT'D)
B) Scheduling a test. 
C) Reporting normal test results. 
D) Requesting a referral. 
E) Services which are part of care plan oversight or anticoagulation management (CPT codes 99339-99340, 99374-99380 or 99363-99364). 
F) Services which relate to or take place within the postoperative period of a procedure provided by the physician are not separately covered. (Such a service is considered part of the procedure and is not to be billed separately.)
Codes eligible for telehealth delivery include 90785, 90791, 90792, 90832-90834, 90836, 90837-90840, 90846, 90847, 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964-90970, 96116, 96156-96171, 96160, 96161, 97802-97804, 98000-98015,99201-99205, 99211-99215, 99231-99233, 99307-99310, 99354-99357, 99401-99404, 99406-99407, 99495-99498, G0108-G0109, G0270, G0296, G0396, G0397, G0406-G0408, G0420, G0421, G0425-G0427, G0438-G0439, G0442-G0447, G0459, G0506, G0508, G0509, G0513, G0514, G2086-G2088. Codes eligible for teledentistry include CDT D0120-D0170, D0180, D0190, D0191, D1206, D1320, D1321, D1330, and D9991-D9997. Additional codes are covered when otherwise appropriate according to this guideline note and other applicable coverage criteria.
The originating site code Q3014 is covered only when the patient is present in an appropriate health care setting and receiving services from a provider in another location.
Clinician to Patient Services billed using specified codes indicating telephone or online service delivery
Covered telephonic and online services include services related to evaluation, assessment and management as well as other technology-based services (CPT *98016, 98966-98968, 99441-99443, 99421-99423, 98970-98972, G2061-G2063, G2251-G2252).
Covered telephone and online services billed using these codes do not include either of the following: 
ANCILLARY GUIDELINE A5, TELEHEALTH, TELECONSULTATIONS AND ONLINE/TELEPHONIC SERVICES (CONT'D)
A) Services related to a service performed and billed by the physician or qualified health professional within the previous seven days, regardless of whether it is the result of patient-initiated or physician-requested follow-up. 
B) Services which result in the patient being seen within 24 hours or the next available appointment.
Clinician-to-Clinician Consultations (telephonic, online or using electronic health record)
Covered interprofessional consultations delivered online, through electronic health records or by telephone (CPT *99446-99449, 99451-99452).
Store and Forward 
Store and forward codes (HCPCS G2010, G2250) are only covered when billed concurrently with a code that includes medical decision making and communication with the patient (for example, HCPCS G2012).
ANCILLARY GUIDELINE A6, CHIMERIC ANTIGEN RECEPTOR T-CELL (CAR-T) THERAPY
Chimeric antigen receptor T-cell (CAR-T) therapy is covered when the treatment is an FDA-approved biological, providing targeted therapy for a known antigen expressed in the patient's cancer according to an FDA indication. Repeat treatment when a patient receives more than one therapeutic dose of a specific CAR T-cell product using the same biological in the same patient is covered only when a new primary cancer diagnosis is made by the treating oncologist and the patient conditions are met.
ANCILLARY GUIDELINE A7, NITROUS OXIDE
Nitrous oxide is covered for labor pain, dental procedures and medical procedures.
DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE
DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE (CONT'D)
A) Genetic tests are covered as diagnostic, unless they are listed below in section F1 as excluded or have other restrictions listed in this guideline. To be covered, initial screening (e.g., physical exam, medical history, family history, laboratory studies, imaging studies) must indicate that the chance of genetic abnormality is > 10% and results would do at least one of the following: 
1) Change treatment,
2) Change health monitoring,
3) Provide prognosis, or
4) Provide information needed for genetic counseling for patient; or patient's parents, siblings, or children
B) Pretest and posttest genetic counseling is required for presymptomatic and predisposition genetic testing. Pretest and posttest genetic evaluation (which includes genetic counseling) is covered when provided by a suitable trained health professional with expertise and experience in genetics. 
1) "Suitably trained" is defined as board certified or active candidate status from the American Board of Medical Genetics, American Board of Genetic Counseling, or Genetic Nursing Credentialing Commission.
C) A more expensive genetic test (generally one with a wider scope or more detailed testing) is not covered if a cheaper (smaller scope) test is available and has, in this clinical context, a substantially similar sensitivity. For example, do not cover CFTR gene sequencing as the first test in a person of Northern European Caucasian ancestry because the gene panels are less expensive and provide substantially similar sensitivity in that context.
D) Related to diagnostic evaluation of individuals with intellectual disability (defined as a full scale or verbal IQ < 70 in an individual > age 5), developmental delay (defined as a cognitive index <70 on a standardized test appropriate for children < 5 years of age), Autism Spectrum Disorder, or multiple congenital anomalies: 
1) CPT *81228, 81229 and 81349, Cytogenomic constitutional microarray analysis: Cover for diagnostic evaluation of individuals with intellectual disability/developmental delay; multiple congenital anomalies; or, Autism Spectrum Disorder accompanied by at least one of the following: dysmorphic features including macro or microcephaly, congenital anomalies, or intellectual disability/developmental delay in addition to those required to diagnose Autism Spectrum Disorder.
DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE (CONT'D)
2) CPT *81243, 81244, 81171,81172 Fragile X genetic testing is covered for individuals with intellectual disability/developmental delay. Although the yield of Fragile X is 3.5-10%, this is included because of additional reproductive implications. 
3) Additional testing that might be appropriate based on physical exam findings include Rett syndrome testing (CPT *81302-81304) and PTEN testing (CPT *81321-81323). Whole exome sequencing (81415-81416) may be considered when all of the testing above is non-diagnostic and after a genetic counseling/geneticist consultation.
4) A visit with the appropriate specialist (often genetics, developmental pediatrics, or child neurology), including physical exam, medical history, and family history is covered. Physical exam, medical history, and family history by the appropriate specialist, prior to any genetic testing is often the most cost-effective strategy and is encouraged.
E) Related to genetic testing for recurrent pregnancy loss:
1) Karyotyping, FISH, and array CGH testing of products of conception are covered for the second or subsequent spontaneous abortion or when a fetal anomaly was present
F) Related to other tests with specific CPT codes:
1) Certain genetic tests have not been found to have proven clinical benefit. These tests are listed in Excluded Services Guideline 2.
2) The following tests are covered only if they meet the criteria in section A above AND the specified situations:
a) CPT *81205, BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X): Cover only when the newborn screening test is abnormal and serum amino acids are normal
b) Diagnostic testing for cystic fibrosis (CF)
i) CFTR, cystic fibrosis transmembrane conductance regulator tests. CPT *81220-81224: For infants with a positive newborn screen for cystic fibrosis or who are symptomatic for cystic fibrosis, or for clients that have previously been diagnosed with cystic fibrosis but have not had genetic testing, CFTR gene analysis of a panel containing at least the mutations recommended by the American College of Medical Genetics2 (CPT *81220) is covered.
DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE (CONT'D)
c) CPT *81224, CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; introm 8 poly-T analysis (e.g., male infertility): Covered only after genetic counseling.
d) CPT *81225-81227, 81230-81231, 81418, 0380U (cytochrome P450). Covered only for determining eligibility for medication therapy if required or recommended in the FDA labelling for that medication. These tests have unproven clinical utility for decisions regarding medications when not required in the FDA labeling (e.g., psychiatric, anticoagulant, opioids).
e) CPT *81240, F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant: Factor 2 20210G>A testing should not be covered for adults with idiopathic venous thromboembolism; for asymptomatic family members of patients with venous thromboembolism and a Factor V Leiden or Prothrombin 20210G>A mutation; or for determining the etiology of recurrent fetal loss or placental abruption.
f) CPT *81241, F5 (coagulation Factor V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant: Factor V Leiden testing should not be covered for: adults with idiopathic venous thromboembolism; for asymptomatic family members of patients with venous thromboembolism and a Factor V Leiden or Prothrombin 20210G>A mutation; or for determining the etiology of recurrent fetal loss or placental abruption. 
g) CPT *81247, G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; common variant(s) (e.g., A, A-) should only be covered
i) After G6PD enzyme activity testing is done and found to be normal; AND either
a. There is an urgent clinical reason to know if a deficiency is present, e.g., in a case of acute hemolysis; OR 
b. In situations where the enzyme activity could be unreliable, e.g., female carrier with extreme Lyonization.
h) CPT *81248, G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; known familial variant(s) is only covered when the information is required for genetic counseling.
DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE (CONT'D)
i) CPT *81249, G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; full gene sequence is only covered 
i) after G6PD enzyme activity has been tested, and
ii) the requirements under CPT *81247 above have been met, and 
iii) common variants (CPT *81247) have been tested for and not found.
j) CPT *81256, HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, common variants (e.g., C282Y, H63D): Covered for diagnostic testing of patients with elevated transferrin saturation or ferritin levels. Covered for predictive testing ONLY when a first degree family member has treatable iron overload from HFE.
k) CPT *81332, SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (e.g., alpha-1-antitrypsin deficiency), gene analysis, common variants (e.g., *S and *Z): The alpha-1-antitrypsin protein level should be the first line test for a suspected diagnosis of AAT deficiency in symptomatic individuals with unexplained liver disease or obstructive lung disease that is not asthma or in a middle age individual with unexplained dyspnea. Genetic testing of the anpha-1 phenotype test is appropriate if the protein test is abnormal or borderline. The genetic test is appropriate for siblings of people with AAT deficiency regardless of the AAT protein test results.
l) CPT *81415-81416, exome testing: A genetic counseling/geneticist consultation is required prior to ordering test
m) CPT *81430-81431, Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel: Testing for mutations in GJB2 and GJB6 need to be done first and be negative in non-syndromic patients prior to panel testing.
n) CPT *81440, 81460, 81465, mitochondrial genome testing: A genetic counseling/geneticist or metabolic consultation is required prior to ordering test.
o) CPT *81425-81427, whole genome sequencing: testing is only covered when
i) The testing is for a critically ill infant up to one year of age admitted to an inpatient intensive care unit (NICU/PICU) with a complex illness of unknown etiology; AND
DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE (CONT'D)
ii) Whole genome sequencing is recommended by a medical geneticist or other physician sub-specialist, including but not limited to a neonatologist or pediatric intensivist with expertise in the conditions and/or genetic disorder for which testing is being considered.
1 Screening for autosomal recessive and X-linked conditions during pregnancy and preconception: a practice resource of the American College of Medical Genetics and Genomics (ACMG) 2021, found at https://www.gimjournal.org/article/S1098-3600(21)05120-0/fulltext  
2 American College of Medical Genetics Statement: updated recommendations for CFTR carrier screening 2023, found at 
https://www.gimjournal.org/action/showPdf?pii=S1098-3600%2823%2900880-8
DIAGNOSTIC GUIDELINE D2, IMPLANTABLE CARDIAC LOOP RECORDERS/SUBCUTANEOUS CARDIAC RHYTHM MONITORS
Use of an implantable cardiac loop recorder (ICLR)/subcutaneous cardiac rhythm monitor is a covered service only when the patient meets all of the following criteria:
1) The evaluation is for recurrent transient loss of consciousness (TLoC); and
2) A comprehensive evaluation including 30 days of noninvasive ambulatory cardiac monitoring did not demonstrate a cause of the TLoC; and
3) A cardiac arrhythmia is suspected to be the cause of the TLoC; and
4) There is a likely recurrence of the TLoC within the battery longevity of the device.
ICLRs and subcutaneous cardiac rhythm monitors are not a covered service for evaluation of cryptogenic stroke or any other indication.
DIAGNOSTIC GUIDELINE D3, ECHOCARDIOGRAMS WITH CONTRAST FOR CARDIAC CONDITIONS OTHER THAN CARDIAC ANOMALIES
Need for contrast with an echocardiogram should be assessed and, if indicated, implemented at the time of the original ECHO and not as a separate procedure.
DIAGNOSTIC GUIDELINE D4, ADVANCED IMAGING FOR LOW BACK PAIN
In patients with non-specific low back pain and no "red flag" conditions [see Table D4], imaging is not a covered service; otherwise work up is covered as shown in the table. Repeat imaging is only covered when there is a substantial clinical change (e.g. progressive neurological deficit) or new clinical indication for imaging (i.e. development of a new red flag condition). Repeat imaging for acute exacerbations of chronic radiculopathic pain is not covered.
Electromyelography (CPT *96002-4) is not covered for non-specific low back pain.
Single photon emission computed tomography (SPECT) (CPT *78830-78832) is not covered for routine pre-operative evaluation of neck or back pain. SPECT of the spine may be covered in certain clinical situations (for example, evaluation for possible spinal infection when MRI is contraindicated or for evaluation of spinal stress fractures not visualized on x-ray in adolescents).
Table D4
Low Back Pain - Potentially Serious Conditions ("Red Flags") and Recommendations for Initial Diagnostic Work-up
Possible cause
Key features on history or physical examination
Imaging1
Additional studies1
Cancer
History of cancer with new onset of LBP
MRI
ESR
Cancer
Unexplained weight loss
Failure to improve after 1 month
Age >50 years
Symptoms such as painless neurologic deficit, night pain or pain increased in supine position
Lumbosacral plain radiography
ESR
Cancer
Multiple risk factors for cancer present
Plain radiography or MRI
ESR
Spinal column infection
Fever 
Intravenous drug use
Recent infection
MRI
ESR and/or CRP
Cauda equina syndrome
Urinary retention
Motor deficits at multiple levels
Fecal incontinence
Saddle anesthesia
MRI
None
Vertebral compression fracture
History of osteoporosis
Use of corticosteroids
Older age
Lumbosacral plain radiography
None
Ankylosing spondylitis
Morning stiffness
Improvement with exercise
Alternating buttock pain
Awakening due to back pain during the second part of the night
Younger age
Anterior-posterior pelvis plain radiography
ESR and/or CRP, HLA-B27
Nerve compression/ disorders
(e.g. herniated disc with radiculopathy)
Back pain with leg pain in an L4, L5, or S1 nerve root distribution present < 1 month
Positive straight-leg-raise test or crossed straight-leg-raise test
None
None
Nerve compression/ disorders
(e.g. herniated disc with radiculopathy
Radiculopathic signs2 present >1 month
Severe/progressive neurologic deficits (such as foot drop), progressive motor weakness
MRI3
Consider EMG/NCV
Spinal stenosis

Radiating leg pain
Older age
Pain usually relieved with sitting
(Pseudoclaudication a weak predictor)
None
None
Spinal stenosis

Radiculopathic signs2 present >1 month
Severe/progressive neurologic deficits (such as foot drop), progressive motor weakness
MRI3
Consider EMG/NCV

1Level of evidence for diagnostic evaluation is variable
2Radiculopathic signs are defined for the purposes of this guideline as the presence of any of the following:
A) Markedly abnormal reflexes
B) Segmental muscle weakness
C) Segmental sensory loss
D) EMG or NCV evidence of nerve root impingement
E) Cauda equina syndrome, 
F) Neurogenic bowel or bladder
G) Long tract abnormalities
3Only if patient is a potential candidate for surgery
DIAGNOSTIC GUIDELINE D4, ADVANCED IMAGING FOR LOW BACK PAIN (CONT'D)
Red Flag: Red flags are findings from the history and physical examination that may be associated with a higher risk of serious disorders. 
CRP = C-reactive protein; EMG = electromyography; ESR = erythrocyte sedimentation rate; MRI = magnetic resonance imaging; NCV = nerve conduction velocity.
Extracted and modified from Chou R, Qaseem A, Snow V, et al: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-491.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D5, NEUROIMAGING FOR HEADACHE
Neuroimaging is not covered in patients with a defined tension or migraine type of headache, or a variation of their usual headache (e.g. more severe, longer in duration, or not responding to drugs).
Neuroimaging is covered for headache when a red flag* is present.
*The following represent red flag conditions for underlying abnormality with headache:
A) New onset or change in headache in patients who are aged over 50
B) Thunderclap headache: rapid time to peak headache intensity (seconds to 5 minutes)
C) Focal neurological symptoms (e.g. limb weakness, lack of coordination, numbness or tingling)
D) Non-focal neurological symptoms (e.g. altered mental status, dizziness) 
E) Abnormal neurological examination
F) Headache that changes with posture
G) Headache wakening the patient up (Nota bene migraine is the most frequent cause of morning headache)
DIAGNOSTIC GUIDELINE D5, NEUROIMAGING FOR HEADACHE (CONT'D)
H) Headache precipitated by physical exertion or Valsalva maneuver (e.g. coughing, laughing, straining)
I) Patients with risk factors for cerebral venous sinus thrombosis
J) Jaw claudication
K) Nuchal rigidity
L) New onset headache in a patient with a history of human immunodeficiency virus (HIV) infection
M) New onset headache in a patient with a history of cancer
N) Cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), or short-lasting unilateral neuralgiform headache attacks with cranial autonomic features (SUNA).
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D6, BREAST MRI
Breast MRI is covered in the following circumstances:
A) Annual breast MRI screening for high-risk patients
1) For individuals with a high-risk genetic mutation: according to the Comprehensive Cancer Network Guidelines: Genetic/Familial High-Risk Assessment: Breast, Ovarian and Pancreatic V2.2025 (11/7/24) www.nccn.org 
2) For individuals who received high dose chest radiation (at least 20 Gray) between the ages of 10 and 30 years beginning 8 years after radiation exposure or at age 25, whichever is later
3) For individuals with a lifetime risk of at least 20% as defined by models that are largely dependent on family history, beginning 10 years prior to when the youngest family member was diagnosed with breast cancer (but not prior to age 25 years) or age 40 years, whichever comes first
4) For individuals with atypical ductal hyperplasia (ADH) or lobular neoplasia (LCIS/ALH) and greater than or equal to 20% residual lifetime risk, beginning at diagnosis of ADH or lobular neoplasia but not prior to age 25 years
B) Evaluation of possible breast cancer
DIAGNOSTIC GUIDELINE D6, BREAST MRI (CONT'D)
1) To search for occult breast cancer in patients with Paget's disease of the nipple or in patients with axillary node metastasis when clinical examination and conventional breast imaging fail to detect a primary breast cancer
2) For the further evaluation of suspicious clinical or imaging findings that remain indeterminate after complete mammographic and sonographic evaluations in lesions that do not meet criteria for breast biopsy
C) Preoperative breast MRI
1) For patients with recently diagnosed breast cancer who qualify for MRI screening based on the high-risk criteria in section A above
2) For determining the extent of cancer or presence of multi-focal or multi-centric tumor or the presence of contralateral cancer, in patients with a proven breast cancer and associated clinical or conventional indeterminate imaging findings suspicious for malignancy. This may include patients with invasive lobular carcinoma or extremely dense breast tissue (limiting mammographic sensitivity), or when there are significant discrepancies in the estimated tumor size as measured on clinical exam, mammogram, and ultrasound
D) Evaluation of suspected breast implant rupture
1) Breast MRI is covered for evaluation of suspected breast implant rupture, if the MRI findings will aid the decision-making for implant removal or aid the diagnostic evaluation of indeterminate clinical or conventional imaging findings in patients with implants
Breast MRI is NOT covered for breast cancer screening in women with increased breast density.
Breast PET-CT scanning and breast-specific gamma imaging are not covered for breast cancer screening.
DIAGNOSTIC GUIDELINE D7, NEUROIMAGING IN DEMENTIA
Neuroimaging is covered:
A) To rule out reversible causes of dementia (tumors, normal pressure hydrocephalus and chronic subdural hematoma) via structural neuroimaging only
DIAGNOSTIC GUIDELINE D7, NEUROIMAGING IN DEMENTIA (CONT'D)
B) MRI is covered for monitoring for adverse effects of aducanumab or similar FDA approved medications for treatment of Alzheimer's disease
Neuroimaging is not covered:
A) For screening of asymptomatic patients for dementia
B) To predict progression of the risk of developing dementia in patients with mild cognitive impairment
C) For screening, diagnosis, or monitoring of dementia, with functional neuroimaging (PET, SPECT or fMRI)
1) PET scans are covered for patients being considered for treatment with aducanumab or similar FDA approved medications for treatment of Alzheimer's disease.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D8, DIAGNOSTIC TESTING FOR OBSTRUCTIVE SLEEP APNEA (OSA) 
For adults over the age of 18 years:
A) For patients with clinical signs and symptoms consistent with obstructive sleep apnea (OSA), a home sleep study is the first-line diagnostic test for most patients, when available.
1) For portable devices, Type II-III are included on this line. Type IV sleep testing devices must measure three or more channels, one of which is airflow, to be included on this line. Sleep testing devices that are not Type I-IV and measure three or more channels that include actigraphy, oximetry, and peripheral arterial tone, are included on this line.
B) Polysomnography in a sleep lab is indicated as a first-line test for patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to a neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia.
DIAGNOSTIC GUIDELINE D8, DIAGNOSTIC TESTING FOR OBSTRUCTIVE SLEEP APNEA (OSA) (CONT'D)
C) If a patient has had an inconclusive (or negative) home sleep apnea test and a clinical suspicion for OSA remains, then attended polysomnography is included on this line. Split night diagnostic protocols are required when a diagnosis of OSA is confirmed in the first portion of the night.
D) Repeat sleep studies are covered up to twice a year when one of the following has occurred since the most recent test:
1) recurrence of OSA symptoms
2) weight change of more than 10% of body weight
3) new or worsening health conditions related to OSA
4) upper airway surgical procedures or initial treatment with oral appliances
For children age of 18 or younger:
A) Obstructive sleep apnea (OSA) must be diagnosed by
1) nocturnal polysomnography with an AHI >5 episodes/h or AHI >1 episodes/h with history and exam consistent with OSA, OR 
2) nocturnal pulse oximetry with 3 or more SpO2 drops <90% and 3 or more clusters of desaturation events, or 
a. alternatives desaturation (>3%) index >3.5 episodes/h,OR
3) use of a validated questionnaire (such as the Pediatric Sleep Questionnaire or OSA 18), OR
4) consultation with a sleep medicine specialist.
B) Polysomnography and/or consultation with a sleep medicine specialist to support the diagnosis of OSA and/or to identify perioperative risk is recommended for
1) high-risk children (i.e., children with cranio-facial abnormalities, neuromuscular disorders, Down syndrome, etc.)
2) children with equivocal indications for adenotonsillectomy (such as discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing), children younger than three years of age
DIAGNOSTIC GUIDELINE D8, DIAGNOSTIC TESTING FOR OBSTRUCTIVE SLEEP APNEA (OSA) (CONT'D)
C) Drug-induced sleep endoscopy (CPT *42975) is only covered when ALL of the following criteria are met:
1) The patient is under 21 years of age; AND
2) The patient has OSA diagnosed by polysomnography; AND
3) The patient is being evaluated for upper airway surgery for OSA; AND
4) The patient has at least one of the following:
a) A high-risk condition including but not limited to trisomy 21 (Down's syndrome), craniofacial anomalies, hypotonia, or neurological disorder; OR
b) A known physical airway anomaly.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D9, WIRELESS CAPSULE ENDOSCOPY
A) Wireless capsule endoscopy (CPT *91110 only) is covered for diagnosis of:
1) Obscure GI bleeding suspected to be of small bowel origin with iron deficiency anemia or documented GI blood loss
2) Suspected Crohn's disease with prior negative work up
B) Wireless capsule endoscopy is not covered for:
1) Colorectal cancer screening
2) Confirmation of lesions of pathology normally within the reach of upper or lower endoscopes (lesions proximal to the ligament of Treitz or distal to the ileum)
C) Wireless capsule endoscopy is only covered when the following conditions have been met:
1) Prior studies must have been performed and been non-diagnostic
a) GI bleeding: upper and lower endoscopy
b) Suspected Crohn's disease: upper and lower endoscopy, small bowel follow through
2) Radiological evidence of lack of stricture
3) Only covered once during any episode of illness
4) FDA-approved devices must be used
DIAGNOSTIC GUIDELINE D9, WIRELESS CAPSULE ENDOSCOPY (CONT'D)
5) Patency capsule should not be used prior to procedure
Other types of wireless capsule endoscopy (e.g., 91111-91113) are included on Excluded Services Guideline 2.
DIAGNOSTIC GUIDELINE D10, DIAGNOSTIC CT COLONOGRAPHY
Diagnostic CT colonography (CPT *74261-74262) is covered for evaluation of symptomatic individuals who
A) Are unable to undergo colonoscopy due to known structural problems (for example, colonic obstruction, stricture, or compression or tortuous or redundant colon); OR
B) Who were unable to complete a diagnostic colonoscopy due to colon structural problems. CT colonography may be covered on the same day for those who were unable to complete the diagnostic colonoscopy.
DIAGNOSTIC GUIDELINE D11, MRI OF THE SPINE (CERVICAL AND THORACIC)
MRI of the cervical and thoracic spine is covered in the following situations:
A) Recent onset of major or progressive neurologic deficit (objective evidence of markedly abnormal reflexes, dermatomal muscle weakness, dermatomal sensory loss, EMG or NCV evidence of nerve root impingement), suspected cauda equina syndrome (loss of bowel or bladder control or saddle anesthesia), or neurogenic claudication in patients who are potential candidates for surgery;
B) Clinical or radiological suspicion of neoplasm; or,
C) Clinical or radiological suspicion of infection.
DIAGNOSTIC GUIDELINE D12, UPPER ENDOSCOPY FOR GERD OR DYSPEPSIA SYMPTOMS
Upper endoscopy for uninvestigated dyspepsia or GERD symptoms is covered for:
Patients less than 50 years of age with persistent symptoms following advice on lifestyle modifications and completion of an appropriate course of twice daily PPI therapy or an H. pylori test and treat protocol.
Patients 50 years of age and older
DIAGNOSTIC GUIDELINE D12, UPPER ENDOSCOPY FOR GERD OR DYSPEPSIA SYMPTOMS (CONT'D)
Patients with "alarm symptoms" including, but not limited to, iron deficiency anemia or weight loss
Upper endoscopy is not covered for patients with previous upper endoscopy with non-malignant findings (other than Barrett's esophagus) in the absence of significant new symptoms.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D13, NEXT GENERATION SEQUENCING OF MALIGNANCIES
Next Generation Sequencing (NGS, for example CPT *81479, 81455, 0037U) is covered when all of the following requirements are met:
A) The patient has
1) A tissue diagnosis confirming cancer and has been evaluated by an oncologist or oncologic surgeon; AND
2) Has not been previously tested using the same NGS test for the same primary diagnosis of cancer, unless the criteria in D) below are met; AND
3) Decided to seek further cancer treatment (for example, therapeutic chemotherapy) and has adequate performance status (ECOG 0-2) to undergo such treatment; AND
B) The diagnostic laboratory test using NGS must have:
1) Clinical Laboratory Improvement Amendments (CLIA)-certification; AND
2) The test is being used as a companion diagnostic test in accordance with Food & Drug Administration (FDA)-approved therapeutic labeling; AND
3) Results provided to the treating physician for management of the patient using a report template to specify treatment options; AND
C) A single CPT or HCPCS code is covered for each multigene panel performed on tumor tissue. Additional codes for individual genes and for molecular pathology procedures CPT *81400-81408 are excluded from coverage when the multigene panel is covered under the appropriate CPT or HCPCS code.
DIAGNOSTIC GUIDELINE D13, NEXT GENERATION SEQUENCING OF MALIGNANCIES (CONT'D)
D) Repeat NGS testing may be required in the setting of patients who have clinically progressed per standardized professional guidelines after therapy. Coverage in this situation is limited to 3 times per primary malignancy unless there is indication for additional testing after individualized review of medical necessity.
In addition to the above requirements for NGS, NGS of circulating tumor DNA ("liquid biopsy") is covered only when one of the following criteria are met:
A) The patient is not medically fit for invasive tissue sampling; OR
B) The invasive tissue sample produces insufficient tissue for molecular analysis.
DIAGNOSTIC GUIDELINE D14, COMPUTER ASSISTED NAVIGATIONAL BRONCHOSCOPY
Computer-assisted navigational bronchoscopy (CPT *31627) is covered for EITHER
A) Patients for whom nonsurgical biopsy is indicated when both transthoracic needle biopsy and conventional bronchoscopy are considered inadequate to accomplish the diagnostic or interventional objective; OR
B) The pre-treatment placement of fiduciary markers within lung tumor(s)
DIAGNOSTIC GUIDELINE D15, LIPOPROTEIN(A) TESTING
Repeat lipoprotein(a) testing (CPT *83695) is not medically necessary.
DIAGNOSTIC GUIDELINE D16, OSTEOPOROSIS SCREENING AND MONITORING IN ADULTS
Osteoporosis screening by dual-energy X-ray absorptiometry (DXA) is covered only for women aged 65 or older, and for men or younger women whose 10-year risk of major osteoporotic fracture is equal to or greater than 9.3 percent.
Fracture risk should be assessed by the World Health Organization's FRAX tool or similar instrument. 
Routine osteoporosis screening by DXA is not covered for men.
DIAGNOSTIC GUIDELINE D16, OSTEOPOROSIS SCREENING AND MONITORING IN ADULTS (CONT'D)
The frequency of subsequent monitoring for development of osteoporosis should not be based on DXA scores alone. If rapid change in bone density is expected, more frequent DXA scanning is appropriate (for example, in patients taking glucocorticoids, those with a history of rapid weight loss, those with medical conditions that could result in secondary osteoporosis, etc.).
If there has been no significant change in an individual's risk factors, monitoring by repeat DXA scanning is covered only at the following frequencies: 
* once every two years for those with osteoporosis or advanced osteopenia (T-score of -2.00 or lower)
* once every four years for moderate osteopenia (T-score between -1.50 and -1.99)
* once every ten years for mild osteopenia (T-score between -1.01 and -1.49).
* once every fifteen years for those with normal bone density.
Repeat testing is only covered if the results will influence clinical management. For purposes of monitoring osteoporosis medication therapy, testing at intervals of less than two years is not covered.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D17, PRENATAL GENETIC TESTING
The following types of prenatal genetic testing and genetic counseling are covered for pregnant women:
A) Genetic counseling (CPT *96041, HPCPS S0265) for high-risk women who have family history of inheritable disorder or carrier state, ultrasound abnormality, previous pregnancy with aneuploidy, or elevated risk of neural tube defect.
B) Genetic counseling (CPT *96041, HPCPS S0265) prior to consideration of chorionic villus sampling (CVS), amniocentesis, microarray testing, Fragile X, and spinal muscular atrophy screening  
C) Validated questionnaire to assess genetic risk in all pregnant women
DIAGNOSTIC GUIDELINE D17, PRENATAL GENETIC TESTING (CONT'D)
D) Screening for aneuploidy with any of six screening strategies [first trimester (nuchal translucency, beta-HCG and PAPP-A), integrated, serum integrated, stepwise sequential, contingency, and cell free fetal DNA testing] (CPT *76813, 76814, 81508, 81510, 81511, 81420, 81507, 81512, 82105, 82677, 84163)
E) Ultrasound for structural anomalies between 18 and 20 weeks gestation (CPT *76811, 76812)
F) CVS or amniocentesis (CPT *59000, 59015, 76945,76946, 82106, 88235, 88261-88264, 88267, 88269, 88280, 88283, 88285, 88289,88291) for a positive aneuploidy screen, maternal age >34, fetal structural anomalies, family history of inheritable chromosomal disorder or elevated risk of neural tube defect 
G) Array CGH (CPT *81228, 81229, 81349) when major fetal congenital anomalies are apparent on imaging, or with normal imaging when array CGH would replace karyotyping performed with CVS or amniocentesis in (F) above
H) FISH testing (CPT *88271, 88275, 88291) only if karyotyping is not possible due a need for rapid turnaround for reasons of reproductive decision-making (i.e., at 22w4d gestation or beyond) 
I) Karyotyping, FISH, and array CGH testing of products of conception are covered for the second or subsequent spontaneous abortion or when fetal anomalies are present; Diagnostic Guideline D1, Non-Prenatal Genetic Testing Guideline
J) Whole exome sequencing (CPT *81415-81416) only when standard diagnostic testing (chromosomal microarray analysis and/or karyotype) of the fetus has been performed and is uninformative AND the fetus has one or more fetal anomalies seen on imaging.
The following genetic screening tests are not covered:
A) Serum triple screen
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D18, ADVANCED IMAGING FOR STAGING OF PROSTATE CANCER
MRI is covered for men with histologically proven prostate cancer if knowledge of the T or N stage could affect management. CT of the pelvis is covered only when MRI is contraindicated. 
Radionuclide bone scanning is not covered in men with low risk localized prostate cancer. Low risk is defined as PSA <10 ng/ml and Gleason score 6 or less and clinical stage T1-T2a. 
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D19, SPECT
SPECT (CPT *78451, 78452) is not covered for screening for coronary artery disease in asymptomatic patients.
Stress SPECT (78451, 78452 in conjunction with stress testing) is only covered for diagnosis or risk stratification of coronary artery disease when a stress ECHO is contraindicated, is unavailable or would provide suboptimal imaging (i.e., pre-existing cardiomyopathy, baseline regional wall motion abnormalities, left bundle branch block, paced rhythm, unsuitable acoustic windows due to body habitus, or inability to exercise with inability to utilize dobutamine.)
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D20, OPHTHALMOLOGY DIAGNOSTIC VISITS
Ophthalmology diagnostic visits (CPT *92002, 92004, 92012, 92014, 92081-92083, 92100, 92133, 92134) are covered for the evaluation of serious eye symptoms such as sudden vision loss or eye pain.
DIAGNOSTIC GUIDELINE D21, PHARMACOGENETICS TESTING FOR PSYCHIATRIC MEDICATION MANAGEMENT
Pharmacogenetics testing for management of psychiatric medications is not a covered service.
DIAGNOSTIC GUIDELINE D22, PET SCANS
Diagnosis:
PET Scans are covered for diagnosis only when:
A) The PET scan is for evaluation of either:
1) Solitary pulmonary nodules, small cell lung cancer and non-small cell lung cancer, OR
2) Evaluation of cervical lymph node metastases when CT or MRI do not demonstrate an obvious primary tumor, AND
B) The PET scan will
1) Avoid an invasive diagnostic procedure, OR
2) Assist in determining the optimal anatomic location to perform an invasive diagnostic procedure.
Initial staging:
PET scans are covered for the initial staging when:
A) The staging is for one of the following cancers/situations:
1) Cervical cancer only when initial MRI or CT is negative for extra-pelvic metastasis
2) Head and neck cancer when initial MRI or CT is equivocal
3) Colon cancer
4) Esophageal cancer
5) Solitary pulmonary nodule
6) Non-small cell lung cancer
7) Lymphoma
8) Melanoma
9) Breast cancer ONLY when metastatic disease is suspected AND standard imaging results are equivocal or suspicious
10) Small cell lung cancer
11) Neuroendocrine tumors
DIAGNOSTIC GUIDELINE D22, PET SCANS (CONT'D)
12) Multiple myeloma
13) Thyroid cancers
14) PSMA PET for unfavorable intermediate, high-risk, or very-high-risk prostate cancer, AND
B) Clinical management of the patient will differ depending on the stage of the cancer identified and either:
1) the stage of the cancer remains in doubt after standard diagnostic work up, OR
2) PET replaces one or more conventional imaging studies when they are insufficient for clinical management of the patient.
Monitoring:
For monitoring tumor response during active therapy for purposes of treatment planning, PET is covered for
A) classic Hodgkin's lymphoma treatment
B) metastatic breast cancer ONLY when a change in therapy is contemplated AND PET scan was the imaging modality initially used to find the neoplasm being monitored.
Restaging: 
Restaging is covered only when:
A) the cancer has staging covered above, AND
B) initial therapy has been completed, AND
C) the PET scan is conducted for
1) detecting residual disease, or
2) detecting suspected recurrence, or
3) determining the extent of a known recurrence.
Other indications:
PET scans are covered for preoperative evaluation of the brain in patients who have intractable seizures and are candidates for focal surgery. PET scans are covered for patients being considered for treatment with aducanumab or similar FDA approved medications for treatment of Alzheimer's disease.
Non-covered conditions/situations:
DIAGNOSTIC GUIDELINE D22, PET SCANS (CONT'D)
A) PET scans are NOT covered to monitor tumor response during the planned course of therapy for any cancer other than classic Hodgkin's lymphoma or the limited indication described above for metastatic breast cancer.
B) PET scans are NOT covered for routine follow up of cancer treatment or routine surveillance in asymptomatic patients.
C) PET scans are NOT covered for cardiac evaluation.
DIAGNOSTIC GUIDELINE D23, URINE DRUG TESTING
Urine drug testing (UDT) using presumptive testing is a covered diagnostic benefit when the results will affect treatment planning. Definitive testing is covered as a confirmatory test only when the result of the presumptive testing is inconsistent with the patient's history, presentation, or current prescribed medication plan, and the results would change management.
Definitive testing other than to confirm the results of a presumptive test as specified above is not covered, unless the clinician suspects use of a substance that is inadequately detected by presumptive UDT (e.g., fentanyl). Definitive testing is limited to no more than fourteen drug classes per date of service. 
For patients receiving treatment for a substance use disorder, presumptive testing on up to 36 dates of service and definitive testing on up to 12 dates of service per year are covered. These limits must be applied in accordance with mental health parity law.
For patients receiving chronic opioid therapy for chronic pain, frequency of testing depending on the patient's risk level (using a validated opioid risk assessment tool). Definitive testing should be conducted only for confirmatory purposes as described above and should not exceed 12 dates of service per year:
* Low Risk: Random presumptive testing on up to two dates of service per year
* Moderate Risk: Random presumptive testing on up to four dates of service per year
* High Risk: Random presumptive testing on up to 12 dates of service per year
In patients with unexplained alteration of mental status and when knowledge of drug use is necessary for medical management (e.g., emergency department evaluation for altered mental status), UDT (presumptive and confirmatory definitive testing, if indicated) is covered in excess of the above limitations.
DIAGNOSTIC GUIDELINE D23, URINE DRUG TESTING (CONT'D)
Urine drug testing conducted in accordance with policy of the DHS Office of Child Welfare Programs, when medically necessary, is also covered in excess of these limitations.  
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
DIAGNOSTIC GUIDELINE D24, CARDIAC MAGNETIC RESONANCE IMAGING
Cardiac magnetic resonance imaging (CMR) is covered only after it has been determined that echocardiogram and Doppler studies are inconclusive or expected to be nondiagnostic.
DIAGNOSTIC GUIDELINE D25, HEREDITARY CANCER GENETIC TESTING
Related to genetic testing for patients with cancers suspected to be hereditary, or patients at increased risk due to family history (for example, CPT *81162-81167, 81201-81203, 81212, 81215-81217, 81288, 81292-81300, 81317-81319, 81321-81323, 81432-81435, 81436, 81479), services are provided according to the Comprehensive Cancer Network Guidelines: Genetic/Familial High-Risk Assessment: Breast, Ovarian and Pancreatic V2.2026 (10/10/2025) www.nccn.org, including the table "Summary of Genes and/or Syndromes Included/Mentioned in Other NCCN Guidelines," or the Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric V1.2025 (6/13/25) www.nccn.org.
Genetic counseling should precede genetic testing for hereditary cancer whenever possible.
A) Pre and post-test genetic counseling should be covered when provided by a health professional with expertise and experience in cancer genetics. Genetic counseling is recommended for cancer survivors when test results would affect cancer screening.
B) If timely pre-test genetic counseling is not possible for time-sensitive cases, appropriate genetic testing accompanied by pre- and post- test informed consent and post-test disclosure performed by a health care professional with experience in cancer genetics should be covered.
1) Post-test genetic counseling should be performed as soon as is practical.
DIAGNOSTIC GUIDELINE D26, NEUROBEHAVIORAL STATUS EXAMS AND NEUROPSYCHOLOGICAL TESTING
Neurobehavioral status exams (CPT *96116 and 96121) and neuropsychological testing services (CPT *96132 and 96133) are only covered when all of the following are met:
A) Symptoms are not explained by an existing diagnosis; AND
B) When the results of such testing will be used to develop a care plan.
OR when neuropsychological testing is done as part of the pre-operative evaluation prior to epilepsy surgery as part of the process to determine if the patient is an appropriate surgical candidate or post-operative follow up after epilepsy surgery.
DIAGNOSTIC GUIDELINE D27, SARS-COV-2 (COVID-19) TESTING
Testing for SARS-CoV-2 (COVID-19) virus RNA or viral antigen is a covered diagnostic service. Testing for viral variants/mutations (CPT *87913) is only covered when required to guide patient treatment.
DIAGNOSTIC GUIDELINE D28, MRI IN MULTIPLE SCLEROSIS
MRI of the brain and spine is covered for diagnosis of MS and for monitoring of disease.
DIAGNOSTIC GUIDELINE D29, X-RAY MOTION ANALYSIS OF THE SPINE
X-ray motion analysis, kinematic analysis or similar testing of the spine is not a covered diagnostic service.
DIAGNOSTIC GUIDELINE D30, CARRIER SCREENING
The following tests are covered for a pregnant patient or patient contemplating pregnancy as well as the male reproductive partner:
A) Screening for genetic carrier status with the minimum testing recommended by the American College of Obstetrics and Gynecology1:
1) Screening for cystic fibrosis carrier status (CPT *81220-81224)
2) Screening for fragile X status (CPT *81243, 81244, 81171, 81172)
3) Screening for spinal muscular atrophy (CPT *81329)
4) Screening for Canavan disease (CPT *81200), familial dysautonomia (CPT *81260), and Tay-Sachs carrier status (CPT *81255). Ashkenazi Jewish carrier panel testing (CPT *81412) is covered if the panel would replace and would be of similar or lower cost than individual gene testing including CG carrier testing 
DIAGNOSTIC GUIDELINE D30, CARRIER SCREENING (CONT'D)
5) Screening for hemoglobinopathies (CPT *83020, 83021)
B) Expanded carrier screening (CPT *81443): A genetic counseling/geneticist consultation must be offered prior to ordering test and after results are reported. Expanded carrier testing is ONLY covered when all of the following are met: 
1) The included genes have well-defined phenotypes, AND
2) The included genes result in conditions that have a detrimental effect on quality of life OR cause cognitive or physical impairment OR require surgical or medical intervention, AND
3) The included genes result in conditions that have an onset early in life, AND
4) The included genes result in conditions that must be diagnosable prenatally to inform antenatal interventions and/or changes in delivery management and/or education of parents about special needs after birth, AND
5) The panel includes the minimum testing recommended by the American College of Obstetrics and Gynecology1. 
Note: When expanded carrier screening is billed, individual genetic tests are not covered.
1ACOG Bulletin 690 (Reaffirmed 2023): Carrier Screening in the Age of Genomic Medicine and ACOG Bulletin 691 (2020): Carrier Screening for Genetic Conditions
DIAGNOSTIC GUIDELINE D31, ALZHEIMER'S DISEASE BIOMARKER TESTING
Testing for beta amyloid, neurofilament light chain, or tau proteins (CPT *82233, 82234, 84393, 84394, PLA 0412U, 0443U, 0445U, 0479U, 0503U) is only covered when ALL of the following criteria are met:
A) The testing is used for the assessment of mild cognitive impairment when Alzheimer's disease is suspected; AND
B) The patient is aged 55 or older; AND
C) The patient is being evaluated for disease modifying therapy with FDA labeling requiring biomarker testing; AND
D) The testing is conducted on cerebrospinal fluid (CSF)

EXCLUDED SERVICES GUIDELINE E1, INTERVENTIONS WITH MARGINAL CLINICAL BENEFIT OR LOW COST-EFFECTIVENESS FOR CERTAIN CONDITIONS
The following interventions result in marginal clinical benefit or have low cost-effectiveness and should be excluded from coverage:
Procedure Code
Intervention
Rationale
Last Review
S2300
Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy
More effective treatments are available
September, 2017 
S2900
Surgical techniques requiring use of robotic surgical system
More cost-effective treatments are available
May, 2018 
* 15778
Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (ie, external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma
More cost-effective treatments with lower complication rates are available
November, 2025 
* 45391-45392
Colonoscopy, flexible; with endoscopic ultrasound examination
More costly than equally effective tests
January, 2025 
* 51715
Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck surgical; with thermally-induced capsulorrhaphy
More effective treatments are available
May, 2024 
* 61630
Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous
Similar or worse outcomes than standard therapies
March, 2025 
* 69710


Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone
Less effective than other therapies
August, 2015 
* 81528; 81327; 0421U
FIT-DNA (Cologuard); Chromoscopy; Colosense
Insufficient evidence for use in population screening
August, 2021 
* 81219
CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9
Individual test not cost-effective; should only be done as part of a gene panel
November, 2025 
* 98976, 98977, 98984, 98985, 98986, 99445, 99454, G0322
Remote monitoring of physiologic parameters, 30 days
This code does not require medical decision making nor communication with a patient.
November, 2025 
* G0327
Blood based colorectal cancer screening tests
Insufficient evidence for use in population screening
August, 2025
* 0115U, 0202U, 0223U, 0225U, 0373U, 0556U, 0563U, 0564U,
Upper respiratory virus panels
Uncertain clinical utility
November, 2025
* 80050
General health panel
More costly than equally effective tests
January, 2026
* 87482
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87487
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87492
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87512
Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87530
Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87542
Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87592
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87652
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification
Not the least costly test for the clinical scenario
January, 2026
* 87798
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism
Not the least costly test for the clinical scenario
January, 2026
* 87799
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism
Not the least costly test for the clinical scenario
January, 2026
* 87149
Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed
Not the least costly test for the clinical scenario
January, 2026
* 86328, 86413, 86769
COVID antibody testing
Not the least costly test for the clinical scenario
January, 2026
* 87797
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism
Not the least costly test for the clinical scenario
January, 2026
* 87150
Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed
Not the least costly test for the clinical scenario
January, 2026
* 87153
Culture, typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene)
Not the least costly test for the clinical scenario
January, 2026
* 87623
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44)
Not the least costly test for the clinical scenario
January, 2026
* 87640
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique
Not the least costly test for the clinical scenario
January, 2026
* 87507
Multiplex PCR panel testing of gastrointestinal pathogens > 11 targets
More costly than equally effective tests
January, 2026

EXCLUDED SERVICES GUIDELINE E2, INTERVENTIONS THAT ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS FOR CERTAIN CONDITIONS
The following Interventions are unproven, have no clinically important benefit or have harms that outweigh benefits and should be excluded from coverage:
Procedure Code
Intervention
Rationale
Last Review
0173U, 0175U, 0345U, 0392U, 0411U, 0419U, 0476U, 0477U
Pharmacogenetics testing for management of psychiatric medications
Insufficient evidence of effectiveness
November, 2024 
0219U
Infectious agent (human immunodeficiency virus), targeted viral next-generation sequence analysis (ie, protease [PR], reverse transcriptase [RT], integrase [INT]), algorithm reported as prediction of antiviral drug susceptibility
Insufficient evidence of effectiveness
May, 2023 
0232T
Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
Insufficient evidence of effectiveness
March, 2022 
* 62330, 62331; G0276
Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (ie, CT or fluoroscopy), bilateral, lumbar;
Blinded procedure for lumbar stenosis, PILD, or placebo control, performed in an approved coverage with evidence development (CED) clinical trial
Insufficient evidence of effectiveness
September, 2023 
0390U, 0243U
Maternal serum biomarker tests with or without additional algorithmic analysis for prediction of preeclampsia
Insufficient evidence of effectiveness
November, 2023 
0398T
MRI guided focused ultrasound for the treatment of essential tremor
Insufficient evidence of effectiveness
October, 2018 
A4575, E0446
Topical oxygen therapy
Insufficient evidence of effectiveness
September, 2023 
A9268, A9269
Ingestible vibrating devices for the treatment of constipation
Insufficient evidence of effectiveness
September, 2023 
A9291, A9292, A9293, G0552, G0553, G0554
Digital prescription therapeutics
Insufficient evidence of effectiveness
November, 2024 
C1735, C1736, 0338T, 0339T
Renal denervation
Insufficient evidence of effectiveness
November, 2024 
C1824
Cardiac contractility modulation
Insufficient evidence of effectiveness
November, 2019 
* 64654-64650, 93145, 93146, C1825
Baroreflex activation therapy (BAT)
Insufficient evidence of effectiveness
October, 2025 
C1832
Autograft suspension, including cell processing and application, and all system components
Insufficient evidence of effectiveness 
November, 2021 
C1833
Monitor, cardiac, including intracardiac lead and all system components (implantable)
Insufficient evidence of effectiveness 
November, 2021 
C1839, * 66683
Iris prosthesis
Insufficient evidence of effectiveness
November, 2024 
C2614
Probe, percutaneous lumbar discectomy
Insufficient evidence of effectiveness
May, 2018 
C8003
Medial knee implanted shock absorber therapy
Insufficient evidence of effectiveness
November, 2024 
C8004
Simulation angiogram
Not a therapeutic intervention
March, 2025 
C8005
Bronchoscopy, rigid or flexible, non-thermal transbronchial ablation of lesion(s) by pulsed electric field (pef) energy, including fluoroscopic and/or ultrasound guidance
Insufficient evidence of effectiveness
March, 2025 
C8937
Computer aided detection of breast MRI
Insufficient evidence of effectiveness
November, 2018 
C9733
Non-ophthalmic fluorescent vascular angiography
Unproven therapy
December, 2012 
C9747, * 55880
Ablation of prostate/ablation of malignant prostate tissue, transrectal, high-intensity focused ultrasound (hifu), including imaging guidance
Insufficient evidence of effectiveness
October, 2020 
C9749
Repair of Nasal vestibular lateral wall stenosis with implant(s)
Unproven treatment
August, 2018 
C9751
Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy
Insufficient evidence of effectiveness
November, 2018 
C9754
C9755
Percutaneous arteriovenous fistula formation
Insufficient evidence of benefit
November, 2018 
C9756
Intraoperative near-infrared fluorescence lymphatic mapping of lymph node(s)
Insufficient evidence of effectiveness
November, 2019 
C9757
Laminotomy with repair of annular defect with implantation of bone anchored annular closure device
Insufficient evidence of effectiveness
November, 2019 
C9771
Nasal/sinus endoscopy, cryoablation nasal tissue(s) and/or nerve(s), unilateral or bilateral
Insufficient evidence of effectiveness
January, 2021 
C9764-C9767
; C9772-C9775; * 37262, 37279
Revascularization, endovascular, open or percutaneous, with intravascular lithotripsy
Insufficient evidence of effectiveness
November 2025 
C9781
Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon)
Insufficient evidence of effectiveness
May, 2022 
C9785
Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion
Insufficient evidence of effectiveness
August, 2023 
C9786
Echocardiography image post processing for computer aided detection of heart failure with preserved ejection fraction
Insufficient evidence of effectiveness
August, 2023 
C9787
Gastric electrophysiology mapping with simultaneous patient symptom profiling
Insufficient evidence of effectiveness
August, 2023 
C9788
Optoacoustic breast imaging
Insufficient evidence of effectiveness
September, 2023 
C9790
Histotripsy for malignant renal tissue
Insufficient evidence of effectiveness
September, 2023 
C9791
Magnetic resonance imaging with inhaled hyperpolarized xenon-129 contrast agent, chest, including preparation and administration of agent
Insufficient evidence of effectiveness
September, 2023 
D0422-D0423
Collection and preparation of genetic sample material for laboratory analysis and report Genetic test for susceptibility
to diseases - specimen analysis
Insufficient evidence of
effectiveness
October, 2018 
D9932-D9935

Cleaning and inspection of removable complete or partial denture, maxillary or mandibular
Insufficient evidence of effectiveness
October, 2015 
E0490, E0491, K1028, K1029
Daytime intraoral neuromuscular electrical tongue stimulation for snoring and obstructive sleep apnea
Insufficient evidence of effectiveness
September, 2023 
E0650-E0673,
E0676
Pneumatic compressors and associated appliances, including intermittent devices
Insufficient evidence of effectiveness
November, 2022 
G0069
Subcutaneous immunotherapy in the home
Insufficient evidence of effectiveness; evidence of harm
November, 2018 
G0106, G0120, G0122
Barium enema as a colorectal cancer screening modality
Not indicated as a CRC screening modality
November, 2017 
G0183
Quantitative software measurements of cardiac volume, cardiac chambers volumes and left ventricular wall mass derived from ct scan(s) data of the chest/heart
Insufficient evidence of effectiveness
March, 2025 
G0252
Pet imaging, full and partial-ring pet scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)
Not a recommended test for axillary staging
March, 2018 
G0460,
 G0465
Autologous platelet rich plasma for diabetic or non-diabetic chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment
Insufficient evidence of effectiveness 
May, 2021 
G0482-G0483
Urine drug testing, definitive for 15 or more drug 
classes
No clinical benefit
January, 2023 

Coverage Guidance
G0566
3d radiodensity-value bone imaging, algorithm derived, from previous magnetic resonance examination of the same anatomy
Insufficient evidence of effectiveness
March, 2025 
K1002
Cranial electrotherapy stimulation system (CES)
No clinically important benefit (CES) for chronic pain; insufficient evidence of effectiveness for all othe indications
March, 2020 
K1020
Non-invasive vagus nerve stimulator
Insufficient evidence of effectiveness
March, 2023 
M0076
Prolotherapy
Insufficient evidence of effectiveness
August, 2019 
S2102
Islet cell tissue transplant from pancreas; allogeneic
Insufficient evidence of effectiveness
August, 2019 
S8930
Electrical stimulation of auricular acupuncture points by proprietary electrical stimulation devices, such as P-Stim and E-pulse [note: auricular electroacupuncture provided by a licensed provider in a clinical setting is covered under CPT 97813-97814]
No Evidence of effectiveness
March, 2018 
0720T
Percutaneous electrical nerve field stimulator (PENFS), percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) for irritable bowel syndrome (for example, IB-Stim)
No Evidence of effectiveness
September, 2023 
* 19294, C9726
Intraoperative radiation therapy (IORT) concurrent with partial mastectomy

Placement and removal (if performed) of applicator into breast for intraoperative radiation therapy, add-on to primary breast procedure
Unproven treatment
May, 2018 
* 20552-20553
Injection(s); single or multiple trigger point(s)
No benefit in chronic pain
January, 2025 
* 20560, 20561

Dry needling
Insufficient evidence of effectiveness
November, 2019 
* 20696-20697
Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame)
Insufficient evidence of effectiveness
January, 2009 
* 20939
Bone marrow aspiration for bone grafting, spine surgery
Unproven treatment
November, 2017 
* 20979
Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
Insufficient evidence of effectiveness
February, 2000 
* 20982
Radiofrequency ablation therapy for reduction or eradication of 1 or more bone tumors 
No evidence of effectiveness
2004
* 20983
Cryotherapy ablation therapy for reduction or eradication of 1 or more bone tumors
No evidence of effectiveness
November, 2014 
* 20985
Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less
Insufficient evidence of effectiveness
August, 2018 
* 22836-22838
Anterior thoracic vertebral body tethering
Insufficient evidence of effectiveness
November, 2023 
* 21685
Hyoid myotomy and suspension
Insufficient evidence of effectiveness
December, 2003 
* 22860
Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar
Insufficient evidence of effectiveness
November, 2022 
* 22867-22870;  C1821
Insertion of interlaminar/ interspinous process stabilization/ distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; Interspinous process distraction device (implantable)
Insufficient evidence of effectiveness
August, 2025 
* 27080
Coccygectomy, primary
No evidence of effectiveness
November, 2000 
* 28890
Extracorporeal shock wave, high energy involving the plantar fascia
Insufficient evidence of effectiveness
December, 2005 
* 29868
Arthroscopy, knee, surgical; meniscal transplantation
Insufficient evidence of effectiveness
November, 2007 
* 30469
Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling
Insufficient evidence of effectiveness
November, 2022 
* 31242, 31243
Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation or cryoablation, posterior nasal nerve
Insufficient evidence of effectiveness
November, 2023 
* 31660-31661
Bronchial thermoplasty
Insufficient evidence of effectiveness
August, 2022 
* 32998
Radiofrequency ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) 
Insufficient evidence of effectiveness
October, 2020 
* 33140-33141
Transmyocardial laser revascularization, by thoracotomy
Insufficient evidence of effectiveness
February, 2000 
* 33274 
33275, C1605, C1740
Leadless cardiac pacemakers
Insufficient evidence of effectiveness; evidence of harm
May, 2024 
* 33289, 93264, C2624, G0555
CardioMEMS(tm) - Implantable wireless pulmonary artery pressure monitor for heart failure monitoring
Insufficient evidence of effectiveness
November, 2024 
* 33267, 33268, 33269; 33340
Exclusion of left atrial appendage; Percutaneous transcatheter closure of the left atrial appendage with endocardial implant
Insufficient evidence of effectiveness
November, 2021 
* 33370
Transcatheter placement and subsequent removal of cerebral embolic protection device(s)
Insufficient evidence of effectiveness
November, 2021 
* 33548
Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures)
Insufficient evidence of effectiveness
December, 2005 
* 33927-33929
Total artificial heart
Unproven treatment
January, 2021 
* 36455
Exchange transfusion, blood; other than newborn
Insufficient evidence of effectiveness
November, 2016 
* 36456
Partial exchange transfusion, blood, plasma or crystalloid necessitating the skill of a physician or other qualified health care professional, newborn 
Added to services recommended for Non Coverage file
November, 2016 
* 41512
Tongue base suspension
No clinically important benefit
January, 2014 
* 41530
Submucosal ablation of the tongue base, radiofrequency
Insufficient evidence of effectiveness
December, 2008 
* 43206
Esophagoscopy, flexible, transoral; with optical endomicroscopy
No evidence of effectiveness
December, 2012 
* 43252, 88375
Optical endomicroscopy
Insufficient evidence of effectiveness
December, 2012 
* 43257
Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease
No evidence of effectiveness
January, 2014
* 43284
Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band)
Insufficient evidence of effectiveness
May, 2023 
* 43290; 43889; C9784
Endoscopic sleeve gastroplasty, intragastric bariatric balloon, and similar endoscopic bariatric procedures
Insufficient evidence of effectiveness
November, 2025 
* 43770
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components)
No evidence of effectiveness
May, 2023 
* 44133, 44136

Donor enterectomy and intestinal allotransplantation from living donor
Insufficient evidence of effectiveness
November, 2019 
* 46760
Sphincteroplasty, anal, for incontinence, adult; muscle transplant/implantation artificial sphincter
No evidence of effectiveness
May, 2013
* 50380
Renal autotransplantation, reimplantation of kidney
Insufficient evidence of effectiveness
November, 2000 
* 50705
Ureteral embolization or occlusion
Insufficient evidence of effectiveness
November, 2015 
* 51721, 55881-55882
Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance
Insufficient evidence of effectiveness
November, 2024 
* 52284
Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis
Insufficient evidence of effectiveness
November, 2023 
* 52647
Laser coagulation of prostate
No evidence of effectiveness
March, 2015 

Coverage guidance
* 53451, 53452, 53454
Periurethral transperineal adjustable balloon continence device
Insufficient evidence of effectiveness
November, 2024 
* 53855, C9769
Temporary prostatic stents
Insufficient evidence of effectiveness
May, 2022 
* 53860
Transurethral radiofrequency micro-remodeling of the bladder neck and urethra for stress incontinence
Insufficient evidence of effectiveness
December, 2010 
* 53865-53866
Temporary device for ischemic remodeling for benign prostatic hypertrothy
Insufficient evidence of effectiveness
November, 2024 
* 55873
Cryosurgical ablation of the prostate
Insufficient evidence of effectiveness
October, 2020 
* 55874
Absorbable perirectal spacer for use during prostate cancer radiation therapy 
Unproven treatment
May, 2024 
* 55875
Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
Insufficient evidence of effectiveness
January, 2021 
* 57465
Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect
Insufficient evidence of effectiveness
October, 2020 
* 58565
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
Risk outweighs benefits
August, 2020 
* 58580
Transcervical ablation of uterine fibroid(s)
Insufficient evidence of effectiveness
November, 2023 
* 61635
Transcatheter placement of intravascular stent(s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed
Results in significantly worse outcomes than medical management
March, 2016 
* 61640-61642
Balloon dilation of intracranial vasospasm, percutaneous
Evidence of harm
March, 2016 
* 61645
Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial
No evidence of effectiveness
November, 2015 
* 61650-61651
Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial
No evidence of effectiveness
November, 2015 
* 62263
Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means 
Insufficient evidence of effectiveness
February, 2000 
* 62287, S2348
Percutaneous laser disc decompression
Ozone therapy injections
Radiofrequency denervation
Insufficient evidence of effectiveness
January, 2018 

Coverage guidance
* 62290-62292, 72285, 72295
Discography
Insufficient evidence of effectiveness
August, 2012 
* 64451, 64625

Anesthetic or steroid injection and/or radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance
Insufficient evidence of effectiveness
October, 2025 
* 64454, 64624
Nerve blocks and/or destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
Insufficient evidence of effectiveness
May, 2019 
* 64479-64480
Transforaminal epidural steroid injections, or diagnostic anesthetic injections, cervical and thoracic spine
Insufficient evidence of benefit
August, 2020 

Coverage guidance
* 64490-64495
Facet joint injections 
Insufficient evidence of benefit

January, 2024 
* 64555
Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
Insufficient evidence of effectiveness
October, 2021 
* 64582, 64583
Implantation, revision or replacement of hypoglossal nerve neurostimulator array
Insufficient evidence of effectiveness
October, 2024 
* 64617
Chemodenervation of muscle(s); larynx
No evidence of effectiveness
January, 2014 
* 64628-64629
Thermal destruction of intraosseous basivertebral nerve 
Insufficient evidence of effectiveness
August, 2025 
* 64632
Destruction by neurolytic agent; plantar common digital nerve
Insufficient evidence of effectiveness
March, 2020 
* 64633-64634
Radiofrequency ablation of the cervical and thoracic spine
Insufficient evidence of benefit
October, 2021 

Coverage Guidance
* 64635-64636, C9752, C9753
Radiofrequency ablation of the lumbar and sacral spine
Insufficient evidence of benefit
 October, 2021 

Coverage guidance
* 64640
Destruction by neurolytic agent; other peripheral nerve or branch
Insufficient evidence of effectiveness
October, 2021 
* 68841
Insertion of drug-eluting implant, including punctal dilation when performed, into lacrimal canaliculus, each
Insufficient evidence of effectiveness
November, 2021 
* 69720-69725
Decompression facial nerve
Insufficient evidence of effectiveness
October, 2020 
* 69955
Total facial nerve decompression and/or repair
Insufficient evidence of effectiveness
October, 2020 
* 70554
Functional MRI
Insufficient evidence of effectiveness
May, 2019 
* 75571
CT coronary calcium scoring

Insufficient evidence of benefit
August 2023 

Coverage guidance
* 76376-76377, 93319, C7557, C8001,C9793
3D rendering of imaging studies
No additional proven benefit beyond the standard study, therefore not reimbursed separately
November, 2024 
* 76978, 76979
Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac)
Insufficient evidence of effectiveness
November, 2018 
* 77084
Magnetic resonance (e.g., proton) imaging, bone marrow blood supply
Insufficient evidence of effectiveness
October, 2020 
* 77086
Vertebral fracture assessment using DXA 
Insufficient evidence of effectiveness
October, 2015 
* 77089-77092
Trabecular bone score 
Insufficient evidence of effectiveness
November, 2021 
* 77767
Remote afterloading high dose rate radionuclide skin surface
brachytherapy, includes basic dosimetry
Insufficient evidence of effectiveness
November, 2015 
* 77768
Skin surface brachytherapy
No evidence of effectiveness
November, 2015 
* 78265-78266
Gastric emptying imaging study
No evidence of effectiveness
November, 2015 
* 78429-78434, 78459, 78491-78492

Myocardial imaging, positron emission tomography (PET), metabolic evaluation and/or perfusion
Insufficient evidence of benefit, unclear harms of radiation exposure
November 2019

 Coverage Guidance 
* 81158
Gene expression profile algorithm for kidney transplant rejection
Insufficient evidence of effectiveness
November, 2024
* 81195, 81354, 0260U, 0264U, 0267U, 0300U, 0331U, 0413U, 0454U
Cytogenomic (genome-wide) analysis, hematologic malignancy, structural variants and copy number variants, optical genome mapping (OGM)
Insufficient evidence of effectiveness
November, 2025
* 81232
5-fluorouracil/5-FU and capecitabine drug metabolism
Insufficient evidence of effectiveness
November, 2017 
* 81237
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (e.g., diffuse large B-cell lymphoma) gene analysis, common variant(s) (e.g., codon 646)
Insufficient evidence of effectiveness
November, 2018 
* 81277
Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities
Insufficient evidence of effectiveness
November, 2019 
* 81283
IFNL3 (interferon, lambda 3) (e.g., drug response), gene analysis, rs12979860 variant 
Insufficient evidence of effectiveness
November, 2017 
* 81291
MTHFR (5,10-methylenetetrahydrofolate reductase) gene analysis, common variants
Insufficient evidence of effectiveness
December, 2011 
* 81320
PLCG2 (phospholipase C gamma 2) (e.g., chronic lymphocytic leukemia) gene analysis, common variants (e.g., R665W, S707F, L845F)
Insufficient evidence of effectiveness
November, 2018 
* 81328
SLCO1B1 (solute carrier organic anion transporter family, member 1B1) gene analysis, common variant(s) 
Insufficient evidence of effectiveness
November, 2017 
* 81330
SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) gene analysis, common variants 
Insufficient evidence of effectiveness
December, 2011 
* 81345
TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region)
Insufficient evidence of effectiveness
November, 2018 
* 81346
TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant)
Insufficient evidence of effectiveness
November, 2017 
* 81350
UGT1A1 (UDP glucuronosyl-transferase 1 family, polypeptide A1) (eg, irinotecan metabolism), gene analysis, common variants
Insufficient evidence of effectiveness
December, 2011 
* 81355
VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variants
Insufficient evidence of effectiveness
December, 2011 
* 81417
Re-evaluation of whole exome sequencing
Insufficient evidence of effectiveness
December, 2011
* 81422
Fetal chromosomal microdeletion(s) genomic sequence analysis (eg. DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood 
Insufficient evidence of effectiveness
November, 2016 
* 81470, 81471
X-linked intellectual disability (XLID) genomic sequence panels
Insufficient evidence of effectiveness
November, 2023 
Breast Cancer Gene Expression tests billed with nonspecific codes (e.g. * 81479, 81599, 84999, S3854)
Mammostrat
Oncotype DX Breast DCIS Score
IHC4
Insufficient evidence of effectiveness 
May, 2018

 Coverage guidance 
Prostate Cancer Gene Expression tests billed with nonspecific codes (e.g. * 81479, 81599, 84999)
Oncotype DX Genomic Prostate Score

Unproven Intervention
November, 2022 

Coverage guidance
* 81490
Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm
No evidence of effectiveness
November, 2015 
* 81493
Coronary artery disease, mRNA, gene expression profiling
Insufficient evidence of effectiveness
November, 2015 
* 81500
Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score
No evidence of effectiveness
December, 2012 
* 81503
Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin, transferrin, and pre-
albumin), utilizing serum, algorithm reported as a risk score
No evidence of effectiveness
December, 2012 
* 81504
Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores)
Unproven intervention
August, 2018 
* 81506
Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, HbA1c, insulin, hs-CRP, adiponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm reporting a risk score
No evidence of effectiveness
December, 2012 
* 81525
Oncotype DX for colon cancer
Insufficient evidence of effectiveness
November, 2015 
* 81529
Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis
Insufficient evidence of effectiveness
October, 2020 
* 81535-81536
Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score
No evidence of effectiveness
November, 2015 
* 81538
Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival
No evidence of effectiveness
November, 2015 
* 81539
Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2[hk2]), utilizing plasma or serum, prognostic algorithm reported as a probability score 
Insufficient evidence of effectiveness
January, 2023 
* 81540
Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported
No evidence of effectiveness
November, 2015 
* 81541
Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping)
Insufficient evidence of effectiveness
November, 2022 
* 81545
Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result
No evidence of effectiveness
November, 2015 
* 81546
Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious)
Insufficient evidence of effectiveness
January, 2023 
* 81551
Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1)
Unproven intervention
November, 2017 
* 81552
Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis
Insufficient evidence of effectiveness
November, 2019 
* 81554
Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP])
Insufficient evidence of effectiveness
October, 2020 
* 81558
Gene expression profile algorithm for kidney transplant rejection
Insufficient evidence of effectiveness
November, 2024
* 81560
Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score
Insufficient evidence of effectiveness
November, 2021 
* 82107
Alpha-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP
Insufficient evidence of effectiveness
October, 2020 
* 82777
Galectin-3
No evidence of effectiveness
November, 2015
* 83006
Growth stimulation expressed gene 2 (ST2, Interleukin 1 receptor like-1)
No evidence of effectiveness
November, 2014 
* 83037
Hemoglobin; glycosylated (A1C) by device cleared by FDA for home us3
Insufficient evidence of effectiveness
January, 2006 
* 83529
Interleukin-6 (IL-6)

Insufficient evidence of effectiveness
November, 2021 
* 83698
Lipoprotein-associated phospholipase A2 (Lp-PLA2)
Insufficient evidence of effectiveness
January, 2024 
* 83700-83704, 0377U
Lipoprotein, blood
Insufficient evidence of effectiveness
January, 2024 
* 83722
Lipoprotein, direct measurement; small dense LDL cholesterol
Insufficient evidence of effectiveness
January, 2024 
* 83861
Tear osmolarity
Insufficient evidence of effectiveness
December, 2010 
* 83951
Oncoprotein; des-gamma-carboxy-prothrombin (DCP)
Insufficient evidence of effectiveness
August, 2008 
* 83987
pH; exhaled breath condensate  
Insufficient evidence of effectiveness
December, 2009 
* 84431
Thromboxane metabolite(s)
Insufficient evidence of effectiveness
December, 2009 
* 86001

Allergen specific IgG testing
No clinically important benefit
May, 2025 
* 86005
Allergen specific IgE qualitative, multiallergen screen
Harms outweigh benefits
May, 2025 
* 86152-86153
Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood)
No evidence of effectiveness
December, 2012 
* 86305
Human epididymis protein 4 (HE4)
Insufficient evidence of effectiveness
December, 2009 
* 86356
Mononuclear cell antigen, quantitative (eg, flow cytometry
Insufficient evidence of effectiveness
December, 2007 
* 86386
Nuclear Matrix Protein 22 (NMP22), qualitative
No evidence of effectiveness
December, 2011 
* 87154
Culture, typing; identification of blood pathogen and resistance typing, when performed, by nucleic acid (DNA or RNA) probe, multiplexed amplified probe technique including multiplex reverse transcription, when performed, per culture or isolate, 6 or more targets
Insufficient evidence of effectiveness
November, 2021 
* 87905
Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid)
Insufficient evidence of effectiveness
August, 2008 
* 88120, 88121
Urovysion for bladder cancer
Insufficient evidene of effectiveness
November, 2015
* 88738
Hemoglobin (HGB), quantitative, transcutaneous
Insufficient evidence of effectiveness
December, 2009 
* 88740
Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin
Insufficient evidence of effectiveness
August, 2008 
* 88741
Hemoglobin, quantitative, transcutaneous, per day; methemoglobin
Insufficient evidence of effectiveness
August, 2008 
* 90845
Psychoanalysis
No longer used in clinical practice
November, 2017 
* 90880
Hypnotherapy
No clinically important benefit
August, 2015 
* 90912-90913
Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed
Insufficient evidence of effectiveness
January, 2021 
* 91040
Esophageal balloon distension study
Evidence of ineffectiveness
January, 2024 
* 91111
Capsule endoscopy, esophagus
Insufficient evidence of effectiveness
October, 2021 
* 91112
Gastrointestinal transit and pressure measurement 
Insufficient evidence of effectiveness
October, 2021 
* 91113
Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon
Insufficient evidence of effectiveness
November, 2021 
* 91117
Colon motility (manometric) study
Insufficient evidence of effectiveness
March, 2025 
* 92145
Corneal hysteresis determination
No evidence of effectiveness
November, 2014 
* 92229
Imaging of retina for detection or monitoring of disease; point-of-care automated analysis and report, unilateral or bilateral
Insufficient evidence of effectiveness
October, 2020 
* 92517-92519
Vestibular evoked myogenic potential (VEMP) testing
Insufficient evidence of effectiveness
October, 2020 
* 92548, 92549

Computerized dynamic posturography 
Insufficient evidence of effectiveness
November, 2019 
* 92620-92621
Evaluation of central auditory function
Insufficient evidence of effectiveness
November, 2023 
* 92625
Assessment of tinnitus
Insufficient evidence of effectiveness
January, 2005 
* 92972, C7571
Coronary intravascular lithotripsy
Insufficient evidence of effectiveness
March, 2024 
* 93050
Arterial pressure waveform analysis for assessment of central arterial pressure
Insufficient evidence of effectiveness
November, 2015 
* 93356

Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics
Insufficient evidence of effectiveness
November, 2019 
* 93702
Bioimpedance spectroscopy (BIS)
No evidence of effectiveness
November, 2014 
* 93740
Temperature gradient studies
Insufficient evidence of effectiveness
October, 2015 
* 93895
Quantitative carotid intima media thickness and carotid atheroma evaluation
No evidence of effectiveness
November, 2014 
* 95803
Actigraphy
No clinically important benefit
May, 2024 
* 95919
Quantitative pupillometry with physician or other qualified health care professional interpretation and report, unilateral or bilateral
Insufficient evidence of effectiveness
November, 2022 
* 95928-95929
Central motor evoked potential study
Insufficient evidence of effectiveness
December, 2004 
* 96000-96004
Comprehensive computer-based motion analysis by video-taping and 3D kinematics 

Dynamic surface electromyography
Insufficient evidence of effectiveness
March, 2022 
* 96931-96936
Reflectance confocal microscopy for non-melanoma skin lesions  
Insufficient evidence of effectiveness
January, 2024 
* 97014, 97032, 0278T,
 E0720, E0730, G0283
Transcutaneous electrical nerve stimulation (TENS), frequency specific microcurrent therapy, microcurrent electrical stimulation, and all similar therapies; Scrambler therapy; all similar transcutaneous electrical neurostimulation therapies 
Insufficient evidence of effectiveness for chronic pain and all other indications
January, 2020 for TENS; October, 2021 for cranial electrical stimulation 
* 97022
Application of a modality; whirlpool
Evidence of harm
May, 2016 
* 97024

Application of a modality;  diathermy (eg, microwave)
Insufficient evidence of effectiveness
May, 2016 
* 97028

Application of a modality; ultraviolet

Insufficient evidence of effectiveness
May, 2016 
* 97034
Application of a modality; contrast baths
Insufficient evidence of effectiveness
May, 2016 
* 97035
Application of a modality to 1 or more areas; ultrasound
Insufficient evidence of effectiveness
June, 2011 
* 97036

Application of a modality; Hubbard tank
Evidence of harm
May, 2016 
* 97037
Application of a modality to 1 or more areas; low-level laser therapy (i.e., nonthermal and non-ablative) for post-operative pain reduction
Insufficient evidence of effectiveness
November, 2023 
* 97533
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands
Insufficient evidence of effectiveness
March, 2022 
* 97610
Low frequency, non-contact, non-thermal ultrasound
No clinically important benefit
October, 2013 
0583T, G0561
Insertion of ventilating tubes under local anesthesia in the office setting
Insufficient evidence of effectiveness
October, 2025
* 27458, 27713
Osteotomy with insertion of an externally controlled intramedullary lengthening device
Insufficient evidence of effectiveness
October, 2025
* 52443
Cystourethroscopy with initial transurethral anterior prostate commissurotomy with non-drug coated balloon catheter followed by therapeutic drug delivery into the prostate by a drug-coated balloon catheter
Insufficient evidence of effectiveness
October, 2025
* 55877
Ablation, irreversible electroporation, prostate, 1 or more tumors, including imaging guidance, percutaneous
Insufficient evidence of effectiveness
October, 2025
* 63032
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, with repair of annular defect by implantation of bone-anchored annular closure 
Insufficient evidence of effectiveness
October, 2025
* 64567
Percutaneous electrical nerve field stimulation, cranial nerves, without implantation
Insufficient evidence of effectiveness.
October, 2025
* 75577
Quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, derived from augmentative software analysis of the data set from a coronary computed tomographic angiography, with interpretation and report by
Insufficient evidence of effectiveness.
October, 2025
* 77436-77439
Surface radiation therapy for treatment of cutaneous tumors
Insufficient evidence of effectiveness.
October, 2025
* 97007-97009
Mechanical scalp cooling
Insufficient evidence of effectiveness.
October, 2025
* 47384
Ablation, irreversible electroporation, liver
Insufficient evidence of effectiveness.
October, 2025
* 64728
Decompression, median nerve at the carpal tunnel, percutaneous, with intracarpal tunnel balloon dilation, including ultrasound guidance
Insufficient evidence of effectiveness.
November, 2025
* 86727
Infectious agent detection by nucleic acid (DNA or RNA), joint space pathogens and drug resistance genes, multiplex amplified probe technique, 26 or more targets
Insufficient evidence of effectiveness.
November, 2025
92288
Screening dark adaptation measurement (eg, rod recovery intercept time), with interpretation and report
Insufficient evidence of effectiveness.
November, 2025
97026
Application of a modality to 1 or more areas; infrared
Insufficient evidence of effectiveness.
October, 2025
0598T, 0599T
Noncontact real-time fluorescence wound imaging
Insufficient evidence of effectiveness.
January, 2026





PRACTICE GUIDELINES
GUIDELINE NOTES FOR HEALTH SERVICES
THAT APPEAR ON THE FEBRUARY 1, 2026 LINES OF THE PRIORITIZED LIST
OF HEALTH SERVICES


GUIDELINE NOTE 1, ROUTINE CERVICAL CANCER SCREENING
Line 3
Cervical cancer screening is covered on Line 3 for women:
Age group in years
Type of screening covered
Frequency
<21
None
Never
21-29
Cytology alone
Mandatory HPV testing (87620-87621) is not covered for women age 21-29
Every 3 years
30-65
High-risk human papillomavirus (hrHPV) testing alone, co-testing (hrHPV and cytology) or cytology alone
Co-testing every 5 years
hrHPV testing alone every 5 years
Cytology alone every 3 years
>65
None
Unless adequate screening* has not been achieved, or it is <20 years after regression or appropriate management of a high-grade precancerous lesion 
Never
Women who have had a hysterectomy with removal of cervix for non
cervical cancer related reasons (i.e., other than high grade precancerous lesion, CIN 2 or 3, or cervical cancer) 
None
Never
Women who have abnormal testing 
Per ASCCP** Guideline, until indicated to resume routine screening
Per ASCCP Guideline, until indicated to resume routine screening
* Adequate screening is defined as 3 consecutive negative cytology results or 2 consecutive negative HPV results within 10 years of the cessation of screening, with the most recent test occurring within 5 years.
** American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology guideline (Perkins, 2020)
Women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in-utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive) are intended to have screening more frequently than delineated in this guideline.
GUIDELINE NOTE 2, FETAL SURGERY
Line 1
Fetal surgery is only covered for the following conditions: repair of urinary tract obstructions via placement of a urethral shunt, repair of congenital cystic adenomatoid malformation, repair of extralobal pulmonary sequestration, repair of sacrococcygeal teratoma, therapy for twin-twin transfusion syndrome, and repair of myelomeningocele.
Fetoscopic repair of urinary tract obstruction (S2401) is only covered for placement of a urethral shunt. Fetal surgery for cystic adenomatoid malformation of the lung, extralobal pulmonary sequestration and sacrococcygeal teratoma must show evidence of developing hydrops fetalis.
Certification of laboratory required (76813-76814).
GUIDELINE NOTE 3, PROPHYLACTIC SURGICAL TREATMENT FOR PREVENTION OF CANCER IN WOMEN AT INCREASED RISK
Line 190
Bilateral prophylactic breast removal and/or salpingo-oophorectomy are included on Line 190 for women without a personal history of invasive breast cancer who meet the criteria in the NCCN Clinical Practice Guidelines in Oncology (Genetic/Familial High-Risk Assessment: Breast, Ovarian and Pancreatic V2.2026 (10/10/25) www.nccn.org). Prior to surgery, women without a personal history of breast cancer must have a genetics consultation as defined in section B of the DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE.
Contralateral prophylactic mastectomy is included on Line 190 for women with a personal history of breast cancer.
Hysterectomy is only included on Line 190 for women meeting NCCN criteria as above who undergo the procedure at the time of risk reducing salpingo-oophorectomy.
GUIDELINE NOTE 4, TOBACCO DEPENDENCE, INCLUDING DURING PREGNANCY
Lines 1,5
Pharmacotherapy (including varenicline, bupropion and all five FDA-approved forms of nicotine-replacement therapy) and behavioral counseling are included on this line, alone or in combination, for at least two quit attempts per year. At least two quit attempts per year must be provided without prior authorization, and each attempt can include both pharmacotherapy and behavioral counseling.  Combination drug therapy (i.e., two forms of NRT or NRT plus bupropion) is also included with each quit attempt without prior authorization. However, nicotine inhalers and sprays may be subject to prior authorization. 
A minimum of four counseling sessions of at least 10 minutes each (group or individual, telephonic or in person) are included for each quit attempt. More intensive interventions and group therapy are likely to be the most effective behavioral interventions. During pregnancy, additional intensive behavioral counseling is strongly encouraged. All tobacco cessation interventions during pregnancy are not subject to quantity or duration limits.
Inclusion on this line follows the minimum standard criteria as defined in the Oregon Public Health Division "Standard Tobacco Cessation Coverage" (based on the Patient Protection and Affordable Care Act), available here: https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/TOBACCOPREVENTION/Documents/tob_cessation_coverage_standards.pdf. 
The USPSTF has also made "A" recommendations for screening, counseling, and treatment of pregnant and nonpregnant adults, included in Guideline Note 106.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 5, OBESITY AND OVERWEIGHT
Line 317
Medical treatment of overweight (with known cardiovascular risk factors) and obesity in adults is limited to intensive counseling on nutrition and physical activity, provided by health care professionals. Intensive counseling is defined as face-to-face contact more than monthly. A multidisciplinary team is preferred, but a single clinician could also deliver intensive counseling in primary care or other settings.
Intensive counseling visits are included on this line for 6 months. Intensive counseling visits may continue for an additional 6 months (up to 12 months) as long as there is evidence of continued weight loss or improvement in cardiovascular risk factors based on the intervention. 
Maintenance visits at the conclusion of the intensive treatment are included on this line no more than monthly after this intensive counseling period. The characteristics of effective behavioral interventions include: high intensity programs; multicomponent (including at a minimum diet and exercise), group-based commercial programs; Mediterranean diet; and the following sub-elements -- calorie counting, contact with a dietician, and comparison to peers.
Known cardiovascular risk factors in overweight persons for which this therapy is effective include: hypertension, dyslipidemia, prediabetes, or the metabolic syndrome. 
Treatment of prediabetes with the Diabetes Prevention Program (DPP) is addressed on Line 3 in Guideline Note 179. The DPP program can be used as an alternative to the intensive counseling as above, even in the absence of prediabetes as required by Guideline Note 179. 
Medical treatment of obesity in children up to age 21 is limited to comprehensive, intensive behavioral interventions. For treatment of children up to 12 years old, interventions may be targeted only to parents, or to both parents and children.
Pharmacological treatments and devices (e.g., gastric balloons, duodenal jejunal bypass liners, and vagus nerve blocking devices) for obesity are not intended to be included as services on this line or any other line on the Prioritized List.
GUIDELINE NOTE 6, REHABILITATIVE AND HABILITATIVE THERAPIES
Lines 31,46,57,68,71,73,80,90,91,127,131,132,136,150,153,160,177,182,183,195,199,200,206,252,254,270,283,285,290,298,299,306,314,338,342,345,352,353,356,373,374,396,399,400,406,414,415,420,422,430,441,455,462,465,466,474,480,488,498,542,545,557,574,591
The quantitative limits in this guideline note do not apply to mental health or substance abuse conditions.
A total of 30 visits per year of rehabilitative therapy and a total of 30 visits per year of habilitative therapy (physical, occupational and speech therapy) are included on these lines when medically appropriate. Additional visits, not to exceed 30 visits per year of rehabilitative therapy and 30 visits per year of habilitative therapy, may be authorized in cases of a new acute injury, surgery, or other significant change in functional status.  Children under age 21 may have additional visits authorized beyond these limits if medically appropriate. Massage therapy (CPT *97124) is included in these service limits. When billing CPT *97124, there must be a minimum of 8 minutes of massage provided. Massage is limited to no more than one session per week.
Physical, occupational and speech therapy are only included on these lines when the following criteria are met:
A) therapy is provided by a licensed physical therapist, occupational therapist, speech language pathologist, physician, or other practitioner licensed to provide the therapy, 
B) there is objective, measurable documentation of clinically significant progress toward the therapy plan of care goals and objectives,
C) the therapy plan of care requires the skills of a medical provider, and 
D) the client and/or caregiver cannot be taught to carry out the therapy regimen independently.
No limits apply while in a skilled nursing facility for the primary purpose of rehabilitation, an inpatient hospital or an inpatient rehabilitation unit.
Spinal cord injuries, traumatic brain injuries, or cerebral vascular accidents are not subject to the visit limitations during the first year after an acute injury.
GUIDELINE NOTE 7, ERYTHROPOIESIS-STIMULATING AGENT (ESA) GUIDELINE
Lines 12,59,92,94,111-115,125,133,135,157,158,161,162,178,190,198,199,207,209,213,214,216,228,233,236,237,256-260,269,274,284-286,292,293,311-313,326,336,393-395,399,417,433,545,559
A) Indicated for anemia (Hgb < 10gm/dl or Hct < 30%) induced by cancer chemotherapy given within the previous 8 weeks or in the setting of myelodysplasia.
1) Reassessment should be made after 8 weeks of treatment. If no response, treatment should be discontinued. If response is demonstrated, ESAs should be discontinued once the hemoglobin level reaches 10, unless a lower hemoglobin level is sufficient to avoid the need for red blood cell (RBC) transfusion.
B) Indicated for anemia (Hgb < 10gm/dl or HCT < 30%) associated with HIV/AIDS.
1) An endogenous erythropoietin level < 500 IU/L is required for treatment, and patient may not be receiving zidovudine (AZT) > 4200 mg/week.
2) Reassessment should be made after 8 weeks. If no response, treatment should be discontinued. If response is demonstrated, the lowest ESA dose sufficient to reduce the need for RBC transfusions should be used, and the Hgb should not exceed 11gm/dl.
C) Indicated for anemia (Hgb < 10 gm/dl or HCT <30%) associated with chronic renal disease, with or without dialysis, in the absence of iron deficiency.
1) Reassessment should be made after 12 weeks. If no response, treatment should be discontinued. If response is demonstrated, the lowest ESA dose sufficient to reduce the need for RBC transfusions should be used, and the Hgb should not exceed 11gm/dl. In those not on dialysis, the Hgb level should not exceed 10gm/dl.
GUIDELINE NOTE 8, BARIATRIC SURGERY
Line 317
Bariatric/metabolic surgery (limited to Roux-en-Y gastric bypass, sleeve gastrectomy, biliopancreatic duodenal switch, one anastomosis gastric bypass, single anastomosis duodenal-ileal bypass with gastrectomy) is included on Line 317 with specific criteria for adults and adolescents:
A) For adults aged 18 or older when ALL of the following criteria are met:
1) The patient has obesity with a:
a) BMI 35 kg/m2 or greater; OR
GUIDELINE NOTE 8, BARIATRIC SURGERY (CONT'D)
b) BMI 30-34.9 kg/m2 or greater with Type 2 Diabetes Mellitus which has not met clinical glycemia targets as defined by HbA1c of 8.0% or greater, despite trials of two diabetes medications
2) Participate in an evaluation by a multidisciplinary team in an MBSAQIP-accredited specialty center1:
a) Psychosocial (conducted by a licensed mental health professional)
b) Medical (conducted by a primary care clinician/member of the multidisciplinary team to optimize control of comorbid conditions)
c) Surgical (conducted by a bariatric surgeon)
d) Nutritional (conducted by a licensed dietician)
3) Free from active substance use disorder
4) Free from active use of combustible cigarettes
5) Not currently pregnant and documented counseling regarding the need for use of effective contraception for at least 18 months postoperatively, where indicated
6) Agree to adhere to post-surgical evaluation and post-operative care recommendations, some of which may require lifelong adherence
B) For adolescents aged 13 to 17 years old when ALL of the following criteria are met:
1) The patient has obesity with a:
a) BMI 35 kg/m2 or greater or 120% of the 95th percentile for age and sex AND a clinically significant comorbid condition; OR
b) BMI 40 kg/m2 or greater or 140% of the 95th percentile for age and sex
2) Participate in an evaluation by a multidisciplinary team in an MBSAQIP-accredited specialty center with Adolescent accreditation:
a) Psychosocial (conducted by a licensed mental health professional)
b) Medical (conducted by a primary care clinician/member of the multidisciplinary team to optimize control of comorbid conditions)
c) Surgical (conducted by a bariatric surgeon)
d) Nutritional (conducted by a licensed dietician)
3) Agree to adhere to post-surgical evaluation and post-operative care recommendations, some of which may require lifelong adherence
4) Free from active substance use disorder
5) Free from active use of combustible cigarettes
6) Not currently pregnant and documented counseling regarding the need for use of effective contraception for at least 18 months postoperatively, where indicated
GUIDELINE NOTE 8, BARIATRIC SURGERY (CONT'D)
Repeat bariatric surgery is included when it is a conversion from a less intensive (such as gastric band or sleeve gastrectomy) to a more intensive surgery (e.g., Roux-en-Y).  Repair of surgical complications (excluding failure to lose sufficient weight) are also included on this and other lines. Reversal of surgical procedures and devices is included on this line when benefits of reversal outweigh harms.  
CPT *43999 (Unlisted procedure, stomach) is only included on this line when used for single anastomosis duodenal-ileal bypass with sleeve (SADI-S). It is not included on this line for gastric balloons or endoscopic sleeve gastrectomy or other endoscopic bariatric procedures.
1All surgical services must be provided by a program with current accreditation (as a comprehensive center or low acuity center) by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
GUIDELINE NOTE 9, CORNEAL COLLAGEN CROSS LINKING
Line 307
CPT *0402T is included on this line only when used for conventional epithelium-off corneal collagen cross linking and only for treatment of:
A) progressive keratoconus, OR
B) corneal ectasia following refractive surgery; AND
only when there is objective progressive deterioration in vision.
GUIDELINE NOTE 10, CENTRAL SEROUS CHORIORETINOPATHY AND POSTERIOR CYCLITIS
Lines 357,380
Central serous chorioretinopathy (ICD-10-CM H35.71) is included on Line 380 only for treatment when the condition has been present for three months or longer. Posterior Cyclitis (ICD-10-CM H30.2) should only be treated in patients with 20/40 or worse vision.
GUIDELINE NOTE 11, COLONY STIMULATING FACTOR (CSF) GUIDELINES
Lines 92,94,111-115,125,133,135,157,158,161,162,178,190,198,199,207,209,213,214,216,228,233,236,237,256-260,269,274,284-286,292,311-313,326,393-395,399,417,433,545
A) CSF are not indicated for primary prophylaxis of febrile neutropenia unless the primary chemotherapeutic regimen is known to produce febrile neutropenia at least 20% of the time. CSF should be considered when the primary chemotherapeutic regimen is known to produce febrile neutropenia 10-20% of the time; however, if the risk is due to the chemotherapy regimen, other alternatives such as the use of less myelosuppressive chemotherapy or dose reduction should be explored in this situation.
B) For secondary prophylaxis, dose reduction should be considered the primary therapeutic option after an episode of severe or febrile neutropenia except in the setting of curable tumors (e.g., germ cell), as no disease free or overall survival benefits have been documented using dose maintenance and CSF.
C) CSF are not indicated in patients who are acutely neutropenic but afebrile.
D) CSF are not indicated in the treatment of febrile neutropenia except in patients who received prophylactic filgrastim or sargramostim or in high-risk patients who did not receive prophylactic CSF. High-risk patients include those age >65 years or with sepsis, severe neutropenia with absolute neutrophil count <100/mcl, neutropenia expected to be more than 10 days in duration, pneumonia, invasive fungal infection, other clinically documented infections, hospitalization at time of fever, or prior episode of febrile neutropenia.
E) CSF are not indicated to increase chemotherapy dose-intensity or schedule, except in cases where improved outcome from such increased intensity has been documented in a clinical trial.
F) CSF (other than pegfilgrastrim) are indicated in the setting of autologous progenitor cell transplantation, to mobilize peripheral blood progenitor cells, and after their infusion.
G) CSF are NOT indicated in patients receiving concomitant chemotherapy and radiation therapy.
H) There is no evidence of clinical benefit in the routine, continuous use of CSF in myelodysplastic syndromes. CSF may be indicated for some patients with severe neutropenia and recurrent infections, but should be used only if significant response is documented.
I) CSF is indicated for treatment of cyclic, congenital and idiopathic neutropenia.
GUIDELINE NOTE 12, PATIENT-CENTERED CARE OF ADVANCED CANCER
Lines 92,111-115,124,129,133,135,157,158,162,178,190,198,199,207,209,213,214,216,228,233,236,237,256-260,269,274,284,285,292,311-313,326,369,393-395,417,433,586
Cancer is a complex group of diseases with treatments that vary depending on the specific subtype of cancer and the patient's unique medical and social situation. Goals of appropriate cancer therapy can vary from intent to cure, disease burden reduction, disease stabilization and control of symptoms. Cancer care must always take place in the context of the patient's support systems, overall heath, and core values. Patients should have access to appropriate peer-reviewed clinical trials of cancer therapies. A comprehensive multidisciplinary approach to treatment should be offered including palliative care services (see STATEMENT OF INTENT 1, PALLIATIVE CARE).
Treatment with intent to prolong survival is not a covered service for patients who have progressive metastatic cancer with:
A) Severe co-morbidities unrelated to the cancer that result in significant impairment in two or more major organ systems which would affect efficacy and/or toxicity of therapy; OR
B) A continued decline in spite of best available therapy with a non-reversible Karnofsky Performance Status or Palliative Performance score of <50% with ECOG performance status of 3 or higher which are not due to a pre-existing disability.
Treatments with intent to relieve symptoms or improve quality of life are covered as defined in STATEMENT OF INTENT 1, PALLIATIVE CARE.
Examples include:
A) Single-dose radiation therapy for painful bone metastases with the intent to relieve pain and improve quality of life. 
B) Surgical decompression for malignant bowel obstruction. Single fraction radiotherapy should be given strong consideration for use over multiple fraction radiotherapy when clinically appropriate (e.g., not contraindicated by risk of imminent pathologic fracture, worsening neurologic compromise or radioresistant histologies such as sarcoma, melanoma, and renal cell carcinoma).
C) Medication therapy such as chemotherapy with low toxicity/low side effect agents with the goal to decrease pain from bulky disease or other identified complications. Cost of chemotherapy and alternative medication(s) should also be considered.
GUIDELINE NOTE 12, PATIENT-CENTERED CARE OF ADVANCED CANCER (CONT'D)
To qualify for treatment coverage, the cancer patient must have a documented discussion about treatment goals, treatment prognosis and the side effects, and knowledge of the realistic expectations of treatment efficacy. This discussion may take place with the patient's oncologist, primary care provider, or other health care provider, but preferably in a collaborative interdisciplinary care coordination discussion. Treatment must be provided via evidence-driven pathways (such as NCCN, ASCO, ASH, ASBMT, or NIH Guidelines) when available.
The development of the single fraction radiotherapy portion of this guideline note was informed by a HERC coverage guidance. See http://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx.
GUIDELINE NOTE 13, HEMANGIOMAS, COMPLICATED; PORT WINE STAINS
Lines 318,609,636
Dermatologic hemangiomas (ICD-10-CM D18.01 Hemangioma and Lymphangioma of skin and subcutaneous tissue; D18.01 Hemangioma unspecified site, when used to represent dermatologic hemangiomas) and angiofibromas (ICD-10-CM D23.30 Other benign neoplasm of skin of unspecified part of face, D23.39 Other benign neoplasm of skin of other parts of face) are included on Line 318 when they are ulcerated, infected, recurrently hemorrhaging, or function-threatening (e.g. eyelid hemangioma). Otherwise, they are included on Line 609.
ICD-10-CM Q82.5 (Congenital non-neoplastic nevus) is included on Line 318 only when representing port wine stains. For all other diagnoses, it is included on Line 636. Treatment of port wine stains is only included on Line 318 when treatment is with pulsed dye lasers and:
A) When lesions are located on the face and neck; OR 
B) When lesions are located on the trunk or extremities AND are associated with recurrent bleeding or painful nodules.
Otherwise, treatment of port wine stains is included on Line 636.
GUIDELINE NOTE 14, LASER INTERSTITIAL THERMAL THERAPY FOR REFRACTORY EPILEPSY
Line 173
Laser interstitial thermal therapy (LITT, CPT *61736-61737) for treatment of refractory epilepsy is included on this line only when
GUIDELINE NOTE 14, LASER INTERSTITIAL THERMAL THERAPY FOR REFRACTORY EPILEPSY (CONT'D)
A) The surgery is performed at a Level 4 epilepsy center, AND
B) The patient has failed to respond to, or is intolerant of, at least 2 appropriately chosen medications at appropriate doses, AND
C) The patient has a well-defined epileptogenic foci or critical pathways of seizure propagation accessible by LITT, AND
D) Seizures occur at a frequency that affects the patient's daily living and the neurologist/neurosurgeon document that the LITT procedure will likely significantly improve the patient's quality of life
GUIDELINE NOTE 15, HETEROTOPIC BONE FORMATION
Lines 80,353
Radiation treatment is indicated only in those at high risk of heterotopic bone formation: those with a history of prior heterotopic bone formation, ankylosing spondylitis or hypertrophic osteoarthritis.
GUIDELINE NOTE 16, PROTON BEAM THERAPY FOR CANCER
Lines 92,112,125,129,190,199,236,274,285,292,312,369,393,394
Proton beam therapy is included on Lines 112 CANCER OF EYE AND ORBIT, 125 BENIGN NEOPLASM OF THE BRAIN AND SPINAL CORD and 292 CANCER OF BRAIN AND NERVOUS SYSTEM.
Proton beam therapy is included on Lines 129, 199 and 285 only for: malignant skull base, paranasal sinus (including lethal midline granuloma), spinal, and juxtaspinal tumors. Proton beam therapy is included on Line 312 only for primary hepatocellular carcinoma.
Proton beam therapy is additionally included on Lines 92, 190, 236, 274, 393 and 394 only for pediatric malignant tumors (incident cancer under age 21.)
GUIDELINE NOTE 17, PREVENTIVE DENTAL CARE
Lines 3,53
Dental cleaning is limited to once per 12 months for adults and twice per 12 months for children up to age 21 (D1110, D1120). More frequent dental cleanings may be required for high-risk individuals when dentally appropriate.
GUIDELINE NOTE 17, PREVENTIVE DENTAL CARE (CONT'D)
Fluoride varnish (99188) is included on Line 3 for use with children up to age 21 during well child preventive care visits. Fluoride treatments (D1206 and D1208) are included on Line 53 PREVENTIVE DENTAL SERVICES for use with adults and children during dental visits. The total number of fluoride applications provided in all settings is not to exceed four per twelve months for children under age 21. The number of fluoride treatments is limited to once per 12 months for average risk adults and up to four times per 12 months for high-risk adults when dentally appropriate.
GUIDELINE NOTE 18, VENTRICULAR ASSIST DEVICES
Lines 81,97,262
Ventricular assist devices are covered as a bridge to cardiac transplant; as treatment for pulmonary hypertension when pulmonary hypertension is the only contraindication to cardiac transplant and the anticipated outcome is cardiac transplant; as a bridge to recovery; or as destination therapy.
When used as destination therapy, patients must
A) have chronic end-stage heart failure (New York Heart Association Class IIIB or IV end-stage left ventricular failure) for more than 60 days, AND
B) not be a candidate for heart transplantation, AND 
C) meet all of the following conditions:
1) Have failed to respond to optimal medical management, including beta-blockers and ACE inhibitors (if tolerated) for at least 45 of the last 60 days, or have been balloon pump dependent for 7 days, or IV inotrope dependent for 14 days; and
2) Have a left ventricular ejection fraction (LVEF) <25%; and
3) Have demonstrated functional limitation with a peak oxygen consumption of <14 ml/kg/min unless balloon pump or inotrope dependent or physically unable to perform the test.
D) Have adequate psychological condition and appropriate external psychosocial support for prolonged VAD support
E) Have adequate end organ function
GUIDELINE NOTE 19, NEUROPSYCHOLOGICAL TESTING FOR PTSD
Line 172
Neuropsychological testing is included on this line only when there is question of cognitive deficit or impairment and such testing is required to assist in making the correct diagnosis.
GUIDELINE NOTE 20, ATTENTION DEFICIT/HYPERACTIVITY DISORDERS IN CHILDREN
Line 121
Use of ICD-10-CM F90.9, Attention deficit/hyperactivity disorder, unspecified type, in children age 5 and under, is appropriate only when the following apply:
* Child does not meet the full criteria for the full diagnosis because of their age. 
* For children age 3 and under, when the child exhibits functional impairment due to hyperactivity that is clearly in excess of the normal activity range for age (confirmed by the evaluating clinician's observation, not only the parent/caregiver report), and when the child is very limited in his/her ability to have the sustained periods of calm, focused activity which would be expected for the child's age.
For children age 5 and under diagnosed with disruptive behavior disorders, including those at risk for ADHD, first line therapy is evidence-based, structured "parent-behavior training. Second line therapy is pharmacotherapy.
For children age 6 and over who are diagnosed with ADHD, pharmacotherapy alone or pharmacotherapy with psychosocial/behavioral treatment are included on this line for first line therapy.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 21, SEVERE INFLAMMATORY SKIN DISEASE
Lines 424,477,493,520,528,541,636
Inflammatory skin conditions included in this guideline are:
A) Psoriasis
B) Atopic dermatitis
C) Lichen planus
D) Darier disease 
E) Pityriasis rubra pilaris
F) Discoid lupus
GUIDELINE NOTE 21, SEVERE INFLAMMATORY SKIN DISEASE (CONT'D)
G) Vitiligo
H) Prurigo nodularis
I) Ichthyosis
J) Erythema intertrigo
The conditions above are included on Line 424 if severe, defined as having functional impairment as indicated by Dermatology Life Quality Index (DLQI) greater than or equal to 11 or Children's Dermatology Life Quality Index (CDLQI) greater than or equal to 13 (or severe score on other validated tool) AND one or more of the following:
A) At least 10% of body surface area involved
B) Hand, foot, face, or mucous membrane involvement.
Otherwise, these conditions above are included on Lines 477, 493, 520, 528, 541 and 636.
For severe psoriasis, treatments included on this line are topical agents, phototherapy, targeted immune modulator medications and other systemic medications.
For severe atopic dermatitis/eczema, treatments included on this line are topical and oral medications and phototherapy. Targeted immune modulators (for example, dupilumab) are included on this line when:
A) Prescribed in consultation with a dermatologist or allergist or immunologist, AND
B) The patient has failed (defined as inadequate efficacy, intolerable side effects, or side effects that pose a health risk) a 4 week trial of a combination of topical moderate to high potency topical steroids and a topical non-steroidal agent OR an oral immunomodulator.
JAK inhibitor (for example, upadacitinib or abrocitinib) therapy is included on this line when other immunomodulatory therapy has failed to adequately control disease (defined as inadequate efficacy, intolerable side effects, or side effects that pose a health risk).
ICD-10-CM Q82.8 (Other specified congenital malformations of skin) is included on Line 424 only for Darier disease. 
ICD-10-CM L26 (Exfoliative dermatitis), L49.7-L49.9 (Exfoliation due to erythematous condition involving 70% to >90% of body surface), L53.8 (Other specified erythematous conditions), L53.9 (Erythematous condition, unspecified), and L54 (Erythema in diseases 
GUIDELINE NOTE 21, SEVERE INFLAMMATORY SKIN DISEASE (CONT'D)
classified elsewhere) are included on Line 424 only when representing erythroderma or when the exfoliation extends over 75% of body surface area. Otherwise, these diagnoses are included on Line 493.
Allergy patch testing (CPT *95044) is included on Line 424 only for pairing with severe atopic dermatitis (ICD-10-CM L20.82-L20.9), defined as having functional impairment as indicated by Dermatology Life Quality Index (DLQI) greater than or equal to 11 or Children's Dermatology Life Quality Index (CDLQI) greater than or equal to 13 (or severe score on other validated tool).
GUIDELINE NOTE 22, PLANNED CESAREAN DELIVERY
Line 1
Cesarean delivery on maternal request without medical or obstetrical indication is not included on this line (or the list). Planned cesarean delivery is also not included on this line (or the list) for: small for gestational age; suspected cephalopelvic disproportion; maternal Hepatitis B infection; or maternal Hepatitis C infection.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 23, COLON CANCER SURVEILLANCE
Line 157
A) History and physical exam is indicated every 3 to 6 months for the first three years after primary therapy, then annually thereafter.
B) CEA testing should be performed every 2-3 months after colon resection for at least two years in patients with stage II or III disease for whom resection of liver metastases is clinically indicated
C) Colonoscopy is indicated every 3 to 5 years.
D) No other surveillance testing is indicated.
GUIDELINE NOTE 24, COMPLICATED HERNIAS
Lines 167,511
Complicated inguinal and femoral hernias in men are included on Line 167 if the hernia
A) Causes symptoms of intestinal obstruction and/or strangulation; OR
B) Is incarcerated (defined as non-reducible by physical manipulation); OR
GUIDELINE NOTE 24, COMPLICATED HERNIAS (CONT'D)
C) Causes pain and functional limitations as assessed and documented by a medical professional; OR
D) Affects the patient's ability to obtain or maintain gainful employment.
Otherwise, inguinal and femoral hernias in men are included on Line 511.
Repair of inguinal and femoral hernias in women and in children age 18 or younger are included on Line 167 due to the different natural history of disease in these populations.
Ventral hernias are included on Line 511. Incarcerated ventral hernias (including incarcerated abdominal incisional and umbilical hernias) are included on Line 511, because the chronic incarceration of large ventral hernias does not place the patient at risk for impending strangulation. Ventral hernias are defined as anterior abdominal wall hernias and include primary ventral hernias (epigastric, umbilical, Spigelian), parastomal hernias and most incisional hernias (ventral incisional hernias). ICD-10-CM K42.0, K43.0, K43.3, K43.6 and K46.0 are included on Line 511 when used to designate incarcerated abdominal incisional and umbilical hernias without intestinal obstruction or gangrene, including ventral hernias with only fat or other non-intestinal tissue.
GUIDELINE NOTE 25, BONE MARROW AND STEM CELL TRANSPLANT
Lines 94,113,115,162,178,216,257,258,286,328,393,398
Bone marrow and stem cell transplants are included on these lines only when BOTH the general criteria AND the specific criteria (if any) below are met:
GENERAL TRANSPLANT CRITERIA
A) Transplantation must be the most effective medical treatment, when compared to other alternatives 
B) The patient is a suitable surgical candidate for transplant surgery, included by ALL of the following:
1) No significant uncontrolled comorbidities such as (not an all-inclusive list):
a) End-stage cardiac, renal, hepatic, or other organ dysfunction unrelated to the primary indication for transplant
b) Uncontrolled HIV infection
c) Multiple organ compromise secondary to infection, malignancy, or condition with no known cure
d) Ongoing or recurrent active infections that are not effectively treated
GUIDELINE NOTE 25, BONE MARROW AND STEM CELL TRANSPLANT (CONT'D)
e) Psychiatric instability severe enough to jeopardize adherence to medical regimen
f) Active alcohol or illicit drug dependency; AND
2) No tobacco smoking as determined by the transplant program unless the transplant is done on an emergent basis; AND
3) Demonstrated compliance with medical treatments and ability to understand and comply with the post-transplant immunosuppressive regimen
It is the intent of the Commission that bone marrow/stem cell transplant should be covered if the specific ICD-10-CM code is not included on the same lines as the transplant procedure codes, if it is determined to be the medically appropriate treatment for that particular patient's clinical situation.
Second bone marrow transplants are covered when medically necessary and appropriate.
Allogeneic transplants are medically necessary only when there is a minimum of 5-out-of-6 antigen match for bone marrow and peripheral stem cell transplants, or 4-out-of-6 match for cord blood transplants.
SPECIFIC CRITERIA 
Stem cell transplantation (CPT *38204-38215, 38230-38241) is only included on Line 257 for treatment of high-risk neuroblastoma (ICD-10-CM C74).
The treatment of germ cell cancer with bone marrow/stem cell rescue and transplant is included on Line 216 only after failure of standard chemotherapy.
Allogeneic hematopoietic cell transplantation is included on Line 113 only for treatment of sickle cell disease and only when:
A) Patient has a related human leukocyte antigen (HLA) matched donor; or
B) Patient has an unrelated or HLA mismatched related donor AND severe sickle cell disease (e.g. recurrent chest syndrome, recurrent vaso-occlusive crises, red blood cell alloimmunization on chronic transfusion therapy).
GUIDELINE NOTE 26, PELVIC CONGESTION SYNDROME
Line 519
Pelvic congestion syndrome is included on this line using ICD-10-CM N94.89. This condition does not pair with any vein embolization procedures due to lack of evidence of effectiveness.
GUIDELINE NOTE 27, TREATMENT OF SLEEP APNEA
Line 201
For adults over the age of 18 years:
A) CPAP is covered initially when all of the following conditions are met:
1) 12 week 'trial' period to determine benefit. This period is covered if apnea-hypopnea index (AHI) calculated using the CMS definition of hypopnic episode of at least 4% oxygen desaturation or respiratory disturbance index (RDI) is greater than or equal to 15 events per hour; or if between 5 and 14 events with additional symptoms including one or more of the following: 
a) excessive daytime sleepiness defined as either an Epworth Sleepiness Scale score >10 or daytime sleepiness interfering with ADLs that is not attributable to another modifiable sedating condition (e.g. narcotic dependence), or 
b) documented hypertension, or
c) ischemic heart disease, or 
d) history of stroke
2) Additionally:
a) Providers must provide education to patients and caregivers prior to use of CPAP machine to ensure proper use; and 
b) Positive diagnosis through polysomnogram (PSG) or Home Sleep Test (HST).
B) CPAP coverage subsequent to the initial 12 weeks is based on documented patient tolerance, compliance, and clinical benefit. Compliance (adherence to therapy) is defined as use of CPAP for at least four hours per night on 70% of the nights during a consecutive 30-day period.
C) Mandibular advancement devices (oral appliances) are covered for those for whom CPAP fails or is contraindicated.
D) Hypoglossal nerve stimulation for treatment of obstructive sleep apnea is not included on this line due to insufficient evidence of effectiveness and evidence of harm.
E) Surgical procedures for treatment of obstructive sleep apnea in adults are covered only when the following criteria are met:
1) For uvulopalatopharyngoplasty (UPPP):
GUIDELINE NOTE 27, TREATMENT OF SLEEP APNEA (CONT'D)
a) Documented obstructive sleep apnea based on a sleep study with an apnea-hypopnea index (AHI4*) of 15 or greater [Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoraco-abdominal movement or airflow as compared with baseline, and with at least a 4% oxygen desaturation]; AND
b) Documentation of one or more of the following regarding CPAP:
i) The patient has an inadequate response to continuous positive airway pressure (CPAP) therapy, defined as an AHI4 of 15 or greater despite using CPAP for at least four hours per night on 70% of the nights during a consecutive 30-day period; OR
ii) The patient cannot tolerate CPAP or other appropriate noninvasive non-pharmacologic treatment after a minimum trial of 30 days.  Inability to tolerate CPAP or other appropriate noninvasive non-pharmacologic treatment is defined as either:
a. Inability to use CPAP or other appropriate noninvasive non-pharmacologic treatment for at least four hours per night on 70% of the nights during a consecutive 30-day period, with reasonable attempts having been made to address any medical, mechanical, or psychological problems associated with CPAP or other appropriate noninvasive non-pharmacologic treatment (e.g. adjustment of pressure settings, appropriate medical and humidification, refitting of the mask, trial of alternative pressure delivery systems); OR
b. The lack of availability of an appropriately trained caregiver for patients who are unable to use CPAP without assistance; AND
c) Evidence of retropalatal or combination retropalatal and retrolingual obstruction as the cause of the obstructive sleep apnea
2) For tonsillectomy alone:
a) Documented obstructive sleep apnea based on a sleep study with an apnea-hypopnea index (AHI4*) of 15 or greater [Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoraco-abdominal movement or airflow as compared with baseline, and with at least a 4% oxygen desaturation]; AND
b) Documentation of one or more of the following regarding CPAP:
GUIDELINE NOTE 27, TREATMENT OF SLEEP APNEA (CONT'D)
i) The patient has an inadequate response to continuous positive airway pressure (CPAP) therapy, defined as an AHI4 of 15 or greater despite using CPAP for at least four hours per night on 70% of the nights during a consecutive 30-day period; OR
ii) The patient cannot tolerate CPAP or other appropriate noninvasive non-pharmacologic treatment after a minimum trial of 30 days. Inability to tolerate CPAP or other appropriate noninvasive non-pharmacologic treatment is defined as either
a. Inability to use CPAP or other appropriate noninvasive non-pharmacologic treatment for at least four hours per night on 70% of the nights during a consecutive 30-day period, with reasonable attempts having been made to address any medical, mechanical, or psychological problems associated with CPAP or other appropriate noninvasive non-pharmacologic treatment (e.g. adjustment of pressure settings, appropriate medical and humidification, refitting of the mask, trial of alternative pressure delivery systems); OR
b. The lack of availability of an appropriately trained caregiver for patients who are unable to use CPAP without assistance; AND
c) Tonsil size rated as 3 or 4 on the Brodsky scale (rated 0-4); AND
d) Determined to not be a candidate for concurrent UPPP
3) All other surgeries are included on this line only for children who meet the criteria below.
For children age of 18 years or younger:
A) Adenotonsillectomy is an appropriate first line treatment for children with OSA. Adenoidectomy without tonsillectomy is only covered when a child with OSA has previously had a tonsillectomy, when tonsillectomy is contraindicated, or when tonsillar hypertrophy is not present. More complex surgical treatments are only included on this line for children with craniofacial anomalies.
B) Intranasal corticosteroids are an option for children with mild OSA in whom adenotonsillectomy is contraindicated or for mild postoperative OSA.
C) CPAP is covered for a 3-month trial for children through age 18 who have
1) undergone surgery or are not candidates for surgery, AND
GUIDELINE NOTE 27, TREATMENT OF SLEEP APNEA (CONT'D)
2) have documented residual sleep apnea symptoms (sleep disruption and/or significant desaturations) with residual daytime symptoms (daytime sleepiness or behavior problems)
D) CPAP will be covered for children through age 18 on an ongoing basis if:
1) There is documentation of improvement in sleep disruption and daytime sleepiness and behavior problems with CPAP use, AND
2) Annual re-evaluation for CPAP demonstrates ongoing clinical benefit and compliance with use, defined as use of CPAP for at least four hours per night on 70% of the nights in a consecutive 30-day period
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 28, TROCHANTERIC BURSITIS
Lines 373,494
Trochanteric bursitis (ICD-10-CM M70.6 and M70.7) is included on Line 373 for pairing with physical therapy and steroid joint injections. Trochanteric bursitis is included on Line 494 for pairing with surgical interventions (i.e. CPT *27062).
GUIDELINE NOTE 29, TYMPANOSTOMY TUBES
Lines 386,422,444,472
Tympanostomy tubes (CPT *69433, 69436) are only included on these lines as treatment for:
A) Patients with recurrent acute otitis media (three or more well-documented and separate episodes of acute otitis media in six months or four or more well-documented and separate episodes in the past 12 months with at least one episode in the past six months) in patients who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy, OR 
B) Chronic otitis media with a documented effusion for 3 months or longer in children under age 21 who are at high risk (note: tympanostomy tubes are not medically necessary for adults due to lack of impact on language acquisition):
1) Children at high risk are defined as having one of the following:
a) Permanent hearing loss of 25dB or greater independent of otitis media with effusion; OR
b) Craniofacial anomalies; OR
c) Syndromes that include cognitive, speech, or language delays; OR
GUIDELINE NOTE 29, TYMPANOSTOMY TUBES (CONT'D)
d) Blindness or uncorrectable visual impairment; OR 
e) Cleft palate; OR
f) Developmental delay; OR
g) Intellectual disability; OR
h) Learning disorder; OR 
i) Attention-deficit/hyperactivity disorder; OR
j) Speech and language delay
Formal audiometry is medically necessary for children with chronic otitis media with effusion present for 3 months or longer. Children with language delay, learning problems, or significant hearing loss should have hearing testing upon diagnosis. Children with chronic otitis media with effusion who are not at risk for language delay (such as those with hearing loss <25dB in the better hearing ear) or developmental delay should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected.
Adenoidectomy is included on these lines at the time of tympanostomy tube insertion for children under age 4 with symptoms directly related to the adenoids (for example, ear infection associated with rhinorrhea and/or upper respiratory infection) OR in children aged 4 years or older.
Removal of retained tympanostomy tubes requiring anesthesia (CPT code 69424) or as an office visit, is included on Line 422 as a complication, pairing with ICD-10-CM H74.8.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 30, BUNIONECTOMY
Line 164
Bunionectomy (CPT *28110-28111, 28292-28299) is only included on this line when ALL of the following criteria are met:
A) The patient has documented skeletal maturity; AND
B) The patient has diabetes mellitus; AND
GUIDELINE NOTE 30, BUNIONECTOMY (CONT'D)
C) The patient currently has or has a history of a diabetic foot ulcer stemming solely from the bunion; AND
D) The patient has not responded adequately to at least 6 months of conservative therapy (for example, NSAIDs, protective cushions, modified footwear, wound care, orthotics); AND
E) The patient has documented adequate lower extremity vascular perfusion 
Otherwise, bunion surgery is included on Line 529.
GUIDELINE NOTE 31, COCHLEAR IMPLANTATION
Line 323
Patients will be considered candidates for bilateral cochlear implants if the following criteria are met:
A) Children who are either 
1) Any age with severe to profound sensorineural hearing loss in both ears (defined as 4-frequency PTA > 80 dB HL or 2-frequency PTA > 85), OR
2) Aged 12 months and older with between 65- and 85-dB hearing loss in both ears whose early aided auditory skill development and speech and language progress indicate a persistent, or widening, gap in age appropriate auditory and language skills
B) Adults with bilateral severe to profound sensorineural hearing impairment (defined as >71 dB hearing loss in both ears) with limited benefit from appropriate hearing (or vibrotactile) aids. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition.
C) No medical contraindications
D) High motivation and appropriate expectations (both patient and family, when appropriate)
Patients will be considered candidates for unilateral cochlear implants if the following criteria are met:
A) The patient is a child under age 21; AND
B) Has severe to profound sensorineural hearing loss in one ear (defined as 4-frequency PTA > 90 dB HL) and normal hearing or mild hearing loss in the other ear; AND
GUIDELINE NOTE 31, COCHLEAR IMPLANTATION (CONT'D)
C) Has obtained limited benefit from a one-month or longer trial of an appropriately fitted unilateral hearing aid, CROS hearing aid or another relevant assistive device in the ear to be implanted. Limited benefit as determined by aided speech perception test scores of 5% or less on developmentally appropriate monosyllabic word lists when tested in the ear to be implanted alone.
D) No medical contraindications, including imaging showing no cochlear nerve deficiency in the deaf ear 
E) High motivation and appropriate expectations (both patient and family, when appropriate)
GUIDELINE NOTE 32, CATARACT
Line 294
Cataract extraction is included on this line for cataracts causing symptomatic (i.e. causing the patient to seek medical attention) impairment of visual function not correctable with a tolerable change in glasses or contact lenses resulting in the patient's inability to function satisfactorily while performing activities of daily  living (ADLs). Cataract removal must be likely to restore vision and allow the patient to resume activities of daily living. There are rare instances where cataract removal is medically necessary even if visual improvement is not the primary goal:
A) Hypermature cataract causing inflammation and glaucoma OR 
B) To see the back of the eye to treat posterior segment conditions that could not be monitored due to the poor view and very dense lens opacity (i.e. diabetic retinopathy, glaucoma) OR 
C) Significant anisometropia causing aniseikonia.
GUIDELINE NOTE 33, VITAMIN D TESTING
Lines 29,55,59,100,102,117,151,223,226,238,246,283,286,291,331,336,349
Vitamin D testing (CPT *82306 and 82652) is only a covered service when the patient has one of the following conditions:
A) Chronic kidney disease stage III or greater (ICD-10-CM N04.0-N04.9, N18.30-N18.6, N25.0)
B) Cirrhosis (ICD-10-CM K70.30-K70.41, K71.7, K72.00-K72.91, K74.3-K74.69, P78.81)
C) Hypocalcemia (ICD-10-CM E83.51)
D) Hypercalcemia (ICD-10-CM E83.52)
GUIDELINE NOTE 33, VITAMIN D TESTING (CONT'D)
E) Hypercalciuria (ICD-10-CM R82.994)
F) Hypervitaminosis D (ICD-10-CM E67.3)
G) Parathyroid disorders (ICD-10-CM E20.0, E20.811-E20.819, E20.89, E21.0-E21.3, N25.81)
H) Malabsorption states (ICD-10-CM K50.00-K51.919, K52.0, K90.0, K90.3, K90.49, K90.81, K90.821-K90.89, K91.2, Z98.84)
I) Obstructive jaundice (ICD-10-CM K83.1, Q44.2, Q44.3)
J) Osteomalacia (ICD-10-CM M83.0-M83.9)
K) Paget's disease of bones (ICD-10-CM M88.0-M88.9)
L) Osteoporosis if: 
1) T score on DEXA scan less than -2/5 (Z score at or below -2.0 if under 21 years of age); or 
2) History of fragility fractures or atraumatic fractures; or
3) FRAX greater than 3% (any fracture) with T-score less than -1.5; or
4) Initiating bisphosphonate therapy (vitamin D level should be determined and managed as necessary before bisphosphonate is initiated) (ICD-10-CM M81.0-M81.8)
M) Osteopenia (ICD-10-CM M85.80-M85.88)
N) Other metabolic bone disease (ICD-10-CM M88.0-M88.9)
O) Osteosclerosis/petrosis (ICD-10-CM Q78.2)
P) Rickets (ICD-10-CM E55.0, E83.32)
Q) Vitamin D deficiency on replacement therapy related to a condition listed above; to monitor the efficacy of treatment (ICD-10-CM E55.9)
R) Nephrolithiasis (ICD-10-CM N20.0-N22)
S) Monitoring for complications from medication therapy (ICD-10-CM Z79.899)
GUIDELINE NOTE 34, EXTRACTION OF IMPACTED WISDOM TEETH
Line 341
Extraction of impacted wisdom teeth (D7220, D7230, D7240, D7241, D7250) is only included on this line when there is 
A) Evidence of pathology. Such pathology includes unrestorable caries, non-treatable pulpal and/or periapical pathology, cellulitis, abscess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumor, tooth/teeth impeding surgery or reconstructive jaw surgery, and when a tooth is involved in or within the field of tumor resection OR
GUIDELINE NOTE 34, EXTRACTION OF IMPACTED WISDOM TEETH (CONT'D)
B) Two or more episodes of pericoronitis OR
C) Severe pain directly related to the impacted tooth that does not respond to conservative treatment. (Extraction for pain or discomfort related to normal tooth eruption or for non-specific symptoms such as "headaches" or "jaw pain" is not considered medically or dentally necessary for treatment.)
GUIDELINE NOTE 35, SINUS SURGERY
Lines 285,464,495
Sinus surgery (other than adenoidectomy) is indicated when at least one of the following circumstances occur (A-G):
A) Recurrent acute rhinosinusitis, defined as 4 or more episodes of acute bacterial rhinosinusitis in one year without signs or symptoms of rhinosinusitis between episodes and have failed optimal medical management defined as nasal steroid therapy and nasal saline therapy, in patients who are compliant with oral antibiotics and/or oral corticosteroids for management of acute episodes of rhinosinusitis
OR
B) Chronic sinusitis defined as 12 weeks of continuous symptoms without improvement after appropriate medical therapy (defined as two or more courses of antibiotics with adequate doses AND a trial of 2 or more adequate doses of inhaled and/or oral steroids unless one or more of these therapies are contraindicated) and one or more of the following (1-3):
A) Findings of obstruction or active infection on CT scan OR
B) Symptomatic mucocele OR
C) Negative CT scan but significant disease found on nasal endoscopy
OR
C) Nasal polyposis causing or contributing to sinusitis
OR
D) Complications of sinusitis including subperiosteal or orbital abscess, Pott's puffy tumor, brain abscess or meningitis
OR
E) Invasive or allergic fungal sinusitis
OR
GUIDELINE NOTE 35, SINUS SURGERY (CONT'D)
F) Tumor of nasal cavity or sinuses
OR
G) CSF rhinorrhea
Adenoidectomy (CPT *42830, 42835) is included on Line 464 only for treatment of children with chronic sinusitis who fail appropriate medical therapy.
GUIDELINE NOTE 36, ADENOTONSILLECTOMY FOR INDICATIONS OTHER THAN OBSTRUCTIVE SLEEP APNEA
Lines 42,47,365,537
Tonsillectomy/adenotonsillectomy is an appropriate treatment for patients with one of the following (either A, B, or C):
A) Individuals with a history of recurrent throat infection (both 1 and 2):
1) Throat infections must occur with a frequency of at least:
a) Seven episodes in the past year; or
b) Five episodes per year for 2 years; or
c) Three episodes per year for 3 years; AND
2) Documentation in the medical record for each episode of sore throat which includes at least one of the following:
a) Temperature greater than 38.3 Celsius (100.9 Fahrenheit); or
b) Cervical adenopathy; or
c) Tonsillar exudates or erythema; or
d) Positive test for Group A Beta-hemolytic streptococcus (GABHS); OR
B) A history of two or more peritonsillar abscesses OR when general anesthesia is required for the surgical drainage of a peritonsillar abscess and tonsillectomy is performed at the time of the surgical drainage; OR
C) Unilateral tonsillar hypertrophy in adults; unilateral tonsillar hypertrophy in children with other symptoms suggestive of malignancy.
ICD-10-CM J35.1 and J35.3 are included on Line 365 only for 1) unilateral tonsillar hypertrophy in adults and 2) unilateral tonsillar hypertrophy in children with other symptoms suggestive of malignancy. Bilateral tonsillar hypertrophy and unilateral tonsillar hypertrophy in children without other symptoms suggestive of malignancy are included only on Line 537.
See Guideline Notes D8 and  27 for diagnosis and treatment of obstructive sleep apnea in children.
GUIDELINE NOTE 37, SURGICAL INTERVENTIONS FOR CONDITIONS OF THE BACK AND SPINE OTHER THAN SCOLIOSIS
Lines 343,517
Spine surgery is included on Line 343 only in the following circumstances:
A) Decompressive surgery is included on Line 343 to treat debilitating symptoms due to central or foraminal spinal stenosis, and only when the patient meets the following criteria:
1) Has MRI evidence of moderate or severe central or foraminal spinal stenosis AND either
a) Has neurogenic claudication OR
b) Has objective neurologic impairment consistent with the MRI findings. Neurologic impairment is defined as objective evidence of one or more of the following:
i) Markedly abnormal reflexes
ii) Segmental muscle weakness
iii) Segmental sensory loss
iv) EMG or NCV evidence of nerve root impingement
v) Cauda equina syndrome
vi) Neurogenic bowel or bladder
vii) Long tract abnormalities
Foraminal or central spinal stenosis causing only radiating pain (e.g. radiculopathic pain) is included only on Line 517.
B) Spinal fusion procedures are included on Line 343 for patients with MRI evidence of moderate or severe central or foraminal spinal stenosis only when one of the following conditions are met:
1) spinal stenosis in the cervical spine (with or without spondylolisthesis) which results in objective neurologic impairment as defined above OR
2) spinal stenosis in the thoracic or lumbar spine caused by spondylolisthesis resulting in signs and symptoms of neurogenic claudication and which correlate with x-ray flexion/extension films showing at least a 5 mm translation OR
3) pre-existing or expected post-surgical spinal instability (e.g. degenerative scoliosis >10 deg, >50% of facet joints per level expected to be resected)
GUIDELINE NOTE 37, SURGICAL INTERVENTIONS FOR CONDITIONS OF THE BACK AND SPINE OTHER THAN SCOLIOSIS (CONT'D)
Note: for foraminal stenosis, there must be MRI evidence of moderate or severe foraminal stenosis of the nerve root that correlates with the objective findings above in section A.
For all other indications, spine surgery is included on Line 517.
The following interventions are not included on these lines due to lack of evidence of effectiveness for the treatment of conditions on these lines, including cervical, thoracic, lumbar, and sacral conditions:
* local injections (including ozone therapy injections)
* botulinum toxin injection
* intradiscal electrothermal therapy
* therapeutic medial branch block
* coblation nucleoplasty
* percutaneous intradiscal radiofrequency thermocoagulation
* percutaneous laser disc decompression
* radiofrequency denervation
* intradiscal injections, including platelet rich plasma, stem cells, methylene blue, or ozone
Corticosteroid injections for thoracic or lumbar back pain with or without radiculopathy are only included on Line 517. Diagnostic anesthetic injections for selective nerve root blocks are included on Line 517 for lumbar or sacral symptoms. Corticosteroid injections for cervical spine pain are not included on these lines due to lack of evidence of effectiveness.
The development of this guideline note was informed by HERC coverage guidances on Percutaneous Interventions for Low Back Pain, Percutaneous Interventions for Cervical Spine Pain, Low Back Pain: Corticosteroid Injections and Low Back Pain: Minimally Invasive and Non-Cordicosteroid Percutaneous Interventions. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 38, SUBTALAR ARTHROEREISIS
Line 374
Procedure code S2117 is only covered when not incorporating an implant device.
GUIDELINE NOTE 39, ENDOMETRIOSIS AND ADENOMYOSIS
Lines 1,392
A) Hysterectomy, with or without adnexectomy, for endometriosis may be appropriate when all of the following are documented (1-4):
1) Patient history of (a and b):
a) Prior detailed operative description or histologic diagnosis of endometriosis
b) Presence of pain for more than 6 months with negative effect on patient's quality of life
2) Failure of a 3-month therapeutic trial with both of the following (a and b), unless there are contraindications to use:
a) Hormonal therapy (i or ii):
i) Oral contraceptive pills or patches, progesterone-containing IUDs, injectable hormone therapy, or similar
ii) Agents for inducing amenorrhea (e.g., GnRH analogs or danazol)
b) Nonsteroidal anti-inflammatory drugs
3) Nonmalignant cervical cytology, if cervix is present
4) Negative preoperative pregnancy test result unless patient is postmenopausal or has been previously sterilized
B) Hysterectomy, with or without adnexectomy, for adenomyosis may be appropriate when all of the following are documented (1-5):
1) Patient history of dysmenorrhea, pelvic pain or abnormal uterine bleeding for more than six months with a negative effect on her quality of life.
2) Failure of a six-month therapeutic trial with both of the following (a and b), unless there are contraindications to use:
a) Hormonal therapy (i or ii):
i) Oral contraceptive pills or patches, progesterone-containing IUDs, injectable hormone therapy, or similar
ii) Agents for inducing amenorrhea (e.g., GnRH analogs or danazol)
b) Nonsteroidal anti-inflammatory drugs
3) One of the following (a or b):
a) Endovaginal ultrasound suspicious for adenomyosis (presence of abnormal hypoechoic myometrial echogenicity or presence of small myometrial cysts)
b) MRI showing thickening of the junctional zone > 12mm
GUIDELINE NOTE 39, ENDOMETRIOSIS AND ADENOMYOSIS (CONT'D)
4) Nonmalignant cervical cytology, if cervix is present
5) Negative preoperative pregnancy test unless patient is postmenopausal or has been previously sterilized
GUIDELINE NOTE 40, UTERINE LEIOMYOMA
Lines 402,419
Hysterectomy, myomectomy, uterine artery embolization, or laparoscopic radiofrequency ablation for leiomyomata may be indicated when all of the following are documented (A-D):
A) One of the following (1 or 2):
1) Patient history of 2 out of 3 of the following (a, b and c):
a) Leiomyomata enlarging the uterus to a size of 12 weeks or greater gestation
b) Pelvic discomfort cause by myomata (i or ii or iii):
i) Chronic lower abdominal, pelvic or low backpressure
ii) Bladder dysfunction not due to urinary tract disorder or disease
iii) Rectal pressure and bowel dysfunction not related to bowel disorder or disease
c) Rapid enlargement causing concern for sarcomatous changes of malignancy
2) Leiomyomata as probable cause of excessive uterine bleeding evidenced by (a, b, c and d):
a) Profuse bleeding lasting more than 7 days or repetitive periods at less than 21-day intervals
b) Anemia due to acute or chronic blood loss (hemoglobin less than 10 or hemoglobin less than 11 g/dL if use of iron is documented)
c) Documentation of mass by sonography
d) Bleeding causes major impairment or interferes with quality of life
B) Nonmalignant cervical cytology, if cervix is present
C) Assessment for absence of endometrial malignancy in the presence of abnormal bleeding
D) Negative preoperative pregnancy test result unless patient is postmenopausal or has been previously sterilized
GUIDELINE NOTE 41, SCOLIOSIS
Line 358
Non-surgical treatments of scoliosis (ICD-10-CM M41) are included on Line 358 when:
A) the scoliosis is considered clinically significant, defined as curvature greater than or equal to 25 degrees, or
B) there is curvature with a documented rapid progression.
Surgical treatments of adolescent and adult idiopathic scoliosis (ICD-10-CM M41.1 and M41.2 families) are included on Line 358 only for:
A) patients with documented failure of non-operative management; AND
B) a spinal curvature of greater than 45 degrees
GUIDELINE NOTE 42, SOLID ORGAN TRANSPLANTS
Lines 83,99,238,239,248,261,262,283,307,403
Solid organ transplants are included on these lines only when BOTH the general criteria AND the organ specific criteria below are met:
GENERAL TRANSPLANT CRITERIA 
A) The patient must have irreversible end-stage organ disease or failure and must have medical therapy optimized; AND
B) The patient is a suitable surgical candidate for transplant surgery, included by ALL of the following:
1) No significant uncontrolled co-morbidities such as (not an all-inclusive list):
a) End-stage cardiac, renal, hepatic or other organ dysfunction unrelated to the primary indication for transplant
b) Uncontrolled HIV infection
c) Multiple organ compromise secondary to infection, malignancy, or condition with no known cure
d) Ongoing or recurrent active infections that are not effectively treated
e) Psychiatric instability severe enough to jeopardize adherence to medical regimen 
f) Active alcohol or illicit drug dependency; AND
2) No tobacco smoking as determined by the transplant program unless the transplant is done on an emergent basis (other than for corneal transplants); AND
3) Demonstrated compliance with medical treatments and ability to understand and comply with the post-transplant immunosuppressive regimen
GUIDELINE NOTE 42, SOLID ORGAN TRANSPLANTS (CONT'D)
It is the intent of the Commission that transplant should be covered if the specific ICD-10-CM code is not included on the same lines as the transplant procedure codes if it is determined to be the medically appropriate treatment for that particular patient's clinical situation.
CORNEAL TRANSPLANT
Corneal transplant is covered if the patient meets the "GENERAL TRANSPLANT CRITERIA" as outlined above.
HEART TRANSPLANT
Adults must have New York Heart Association (NYHA) Class III or IV cardiac disease or malignant ventricular arrhythmias unresponsive to medical and/or surgical therapy. Children must have intractable heart failure or a congenital abnormality not amenable to surgical correction.
LUNG TRANSPLANT 
Patients must have symptoms at rest directly related to chronic pulmonary disease and resultant severe functional limitations.
KIDNEY TRANSPLANT 
The patient must have one of the following:
A) End-stage renal disease requiring hemodialysis or continuous ambulatory peritoneal dialysis; OR
B) End-stage renal disease, evidenced by a creatinine clearance below 20mL/min or development of symptoms of uremia; OR
C) Chronic renal failure with anticipated deterioration to end-stage renal disease requiring dialysis
LIVER TRANSPLANT
The patient must have irreversible, end-stage liver damage with no other available treatment options.
PANCREAS TRANSPLANT
Pancreas transplant alone is not included on any transplant line. Simultaneous pancreas/kidney (SPK) transplant is only included on this line for type I diabetes mellitus with 
GUIDELINE NOTE 42, SOLID ORGAN TRANSPLANTS (CONT'D)
end-stage renal disease (ICD-10-CM E10.2). Pancreas after kidney (PAK) transplant is only included on this line for other type I diabetes mellitus with a secondary diagnosis of Z94.0 (Kidney transplant status).
ISLET CELL AUTOTRANSPLANTATION
Islet cell autotransplantation (TP-IAT) is only included on Line 248 when done with total pancreatectomy AND when the patient meets ALL of the following criteria:
A) Has acquired intractable chronic pancreatitis
B) Has intractable abdominal pain despite optimal medical therapy
C) Has not responded to more conservative surgery including endoscopic pancreatic decompression or in whom such surgery is not clinically indicated
D) Has not responded to nerve block procedures or in whom these interventions are not clinically indicated
E) Has been assessed by the multidisciplinary team and determined to have pain of an organic nature and are thought likely to achieve significant pain reduction from TP-IAT
F) Is an appropriate candidate for major surgery
G) Is able to adhere to the complex medical management required following TP-IAT
H) Does not have type 1 diabetes, known pancreatic cancer, or any other condition that would prevent isolation of islet cells for autotransplant
I) Does not have a condition (e.g., portal vein thrombosis or significant parenchymal liver disease such as cirrhosis of the liver) which increases the risks associated with islet cell transplant
J) Does not have any other contraindications such as active alcohol abuse
INTESTINE TRANSPLANT
Intestine transplant is included on this line only for patients with failure of total parenteral nutrition (TPN) as indicated by one of the following, and no contraindications to transplant:
A) Impending or overt liver failure due to TPN, indicated by elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastro-esophageal varices, coagulopathy, peristomal bleeding, or hepatic fibrosis/cirrhosis;
B) Thrombosis of at least 2 central veins, including jugular, subclavian, and femoral veins;
GUIDELINE NOTE 42, SOLID ORGAN TRANSPLANTS (CONT'D)
C) Two or more episodes of systemic sepsis due to line infection, per year, or one episode of septic shock, acute respiratory distress syndrome, and/or line-related fungemia;
D) Frequent episodes of dehydration despite IV fluid supplementation
E) Other complications leading to loss of vascular access
COMBINED ORGAN TRANSPLANTATIONS
The patient must meet criteria for both organs being considered for transplant and there is no reasonable alternative medical or surgical therapy. See criteria above when combined organ transplants include pancreas transplant.
GUIDELINE NOTE 43, LYMPHEDEMA
Lines 283,420
Lymphedema treatments are included on this line when medically appropriate. These services are to be provided by a licensed practitioner who is:
A) Certified by Lymphology Association of North America (LANA, http://www.clt-lana.org), OR
B) CLT-LANA eligible (graduates from a minimum 135-hour lymphedema program that meet the LANA eligibility requirements).
Services should be provided by a LANA certified therapist if available.
Treatments for lymphedema are not subject to the visit number restrictions found in Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES.
ICD-10-CM I97.89 (Other postprocedural complications and disorders of the circulatory system, not elsewhere classified) is only included on Line 420 for post-operative lymphedema. 
It is the intent of the HERC that compression dressings/garments and other medical equipment needed for the treatment of lymphedema be covered even in the absence of ulcers or other complications.
GUIDELINE NOTE 44, MENSTRUAL BLEEDING DISORDERS
Line 421
Endometrial ablation or hysterectomy for abnormal uterine bleeding in Premenopausal women may be indicated when all of the following are documented (A-C):
A) Patient history of (1, 2, 3, 4, and 5):
1) Excessive uterine bleeding evidence by (a, b and c):
a) Profuse bleeding lasting more than 7 days or repetitive periods at less than 21-day intervals
b) Anemia due to acute or chronic blood loss (hemoglobin less than 10 g/dL or hemoglobin less than 11 g/dL if use of iron is documented) for hysterectomy. Note: the anemia requirement does not apply to endometrial ablation procedures.
c) Bleeding causes major impairment or interferes with quality of life
2) Failure of hormonal treatment for a six-month trial period or contraindication to hormone use (oral contraceptive pills or patches, progesterone-containing IUDs, injectable hormone therapy, or similar)
3) No current medication use that may cause bleeding, or contraindication to stopping those medications
4) Endometrial sampling performed
5) For hysterectomy, no evidence of treatable intrauterine conditions or lesions by (a, b or c):
a) Sonohysterography
b) Hysteroscopy
c) Transvaginal ultrasound For endometrial ablation, a pre-operative ultrasound should be performed.
B) Negative preoperative pregnancy test result unless patient has been previously sterilized
C) Nonmalignant cervical cytology, if cervix is present
GUIDELINE NOTE 45, OTHER DISEASES OF VOCAL CORDS
Lines 204,546
ICD-10-CM J38.3 (Other diseases of vocal cords) is included on Line 204 for treatment of abscesses and cellulitis of the vocal cords; it is included on Line 546 for treatment of spastic dysphonia.
GUIDELINE NOTE 46, AGE-RELATED MACULAR DEGENERATION
Line 447
Pegaptanib is only covered for minimally classic and occult lesions of wet macular degeneration.
GUIDELINE NOTE 47, URINARY INCONTINENCE
Line 455
Surgery for genuine stress urinary incontinence may be indicated when all of the following are documented (A-G):
A) Patient history of (1 or 2):
1) Involuntary loss of urine with exertion (for example: laughing, coughing, or sneezing)
2) Identification and treatment of transient causes of urinary incontinence, if present (e.g., delirium, infection, pharmaceutical causes, psychological causes, excessive urine production, restricted mobility, and stool impaction)
B) Patient's voiding habits
C) Physical or laboratory examination evidence of either (1 or 2):
1) Intrinsic sphincter deficiency (closing pressure of <20 cm H2) documented on urodynamic studies)
2) Involuntary loss of urine on examination during stress (provocative test with direct visualization of urine loss) and low or absent post void residual
D) Evaluation to rule out urgency incontinence
E) Negative preoperative pregnancy test result unless patient is postmenopausal or has been previously sterilized
F) Nonmalignant cervical cytology, if cervix is present and clinically appropriate
G) Patient required to have 3 months of alternative therapy (e.g., pessaries or physical therapy, including bladder training and/or pelvic floor exercises, as available). If limited coverage of physical therapy is available, patients should be taught pelvic floor exercises by their treating provider, physical therapist or trained staff, and have documented consistent practice of these techniques over the 3-month period.
GUIDELINE NOTE 48, FRENULECTOMY/FRENULOTOMY
Lines 341,580,641
Labial or buccal frenulectomy/frenulotomy (CDT **D7961; CPT *40806, 40819) and lingual frenectomy (CDT **D7962, CPT *41010, 41115) are only included on Line 341 for children over age 12 and under age 21 in the following situations:
A) When deemed to cause gingival recession; OR
B) When deemed to cause movement of the gingival margin when frenum is placed under tension.
Under age 12, this procedure is not considered medically necessary as these situations generally self-resolve by age 12.
If the above criteria are not met:
A) CDT **D7961 and CPT *40806 are included on Line 641.  
B) CDT **D7962 and CPT *40819 and 41115 are included on Line 580 unless used for cancer treatment or as part of cleft lip/palate repair.  
C) CPT *41010 is included on Line 580 unless meeting tongue tie treatment criteria in Guideline Note 139 criteria or for treatment of oral cancer.
GUIDELINE NOTE 49, WEARABLE CARDIAC DEFIBRILLATORS
Lines 69,98,110,188,279,344
Wearable cardiac defibrillators (WCDs; CPT *93745, HCPCS K0606-K0609) are included on these lines for patients at high risk for sudden cardiac death who meet the medical necessity criteria for an implantable cardioverter defibrillator (ICD) as defined by the CMS 2005 National Coverage Determination but are unable to have an ICD implanted due to medical condition (e.g. ICD explanted due to infection with waiting period before ICD reinsertion or current medical condition contraindicates surgery). WCDs are not included on these lines for use during the waiting period for ICD implantation after myocardial infarction, coronary bypass surgery, or coronary artery stenting.
GUIDELINE NOTE 50, PELVIC ORGAN PROLAPSE SURGERY
Line 466
Hysterectomy, cystocele repair, and/or other surgery for pelvic organ prolapse may be indicated when all of the following are documented (A-E):
A) Patient history of symptoms of pelvic prolapse such as:
GUIDELINE NOTE 50, PELVIC ORGAN PROLAPSE SURGERY (CONT'D)
1) Complaints of the pelvic organs prolapsing at least to the introitus, and one or more of the following:
a) Low back discomfort or pelvic pressure, or 
b) Difficulty in defecating, or
c) Difficulty in voiding
B) For hysterectomy
1) Nonmalignant cervical cytology, if cervix is present, and
2) Assessment for absence of endometrial malignancy in the presence of abnormal bleeding
C) Physical examination is consistent with patient's symptoms of pelvic support defects indicating either symptomatic prolapse of the cervix, enterocele, cystocele, rectocele or prolapse of the vaginal vault
D) Negative preoperative pregnancy test unless patient is postmenopausal or has been previously sterilized
E) Patient required to have 3 months of alternative therapy (e.g., pessaries or physical therapy, including bladder training and/or pelvic floor exercises, as available). If limited coverage of physical therapy is available, patients should be taught pelvic floor exercises by their treating provider, physical therapist or trained staff, and have documented consistent practice of these techniques over the 3-month period.
GUIDELINE NOTE 51, FOOT ORTHOTICS/ORTHOSES 
Lines 46,57,68,71,80,90,91,127,131,132,136,150,160,164,177,182,183,195,199,206,254,270,283,290,299,306,314,338,342,352,353,358,373,374,399,415,420,422,430,441,462,474,480,542,545,557,574,591
Foot orthoses are included on these lines only for prevention of recurrence of foot ulcers resulting from impaired peripheral sensation and/or altered peripheral circulation (for example, diabetic neuropathy, other peripheral neuropathies, and peripheral vascular disease).
Foot orthoses are also covered for other conditions as defined in Oregon Administrative Rule.
GUIDELINE NOTE 52, CHRONIC ANAL FISSURE
Line 391
Surgery for chronic anal fissure (ICD-10-CM K60.1) is included in this line with one or more of the following:
GUIDELINE NOTE 52, CHRONIC ANAL FISSURE (CONT'D)
A) Condition persists or progresses in spite of six weeks of continuous conservative treatment, defined as lifestyle changes (increased fiber intake, increased fluid intake), bulking agents such as psyllium, stool softeners, and topical medications such as nitroglycerin or calcium channel blockers (when such topical medications are available and not contraindicated);
B) Presence of pectenosis;
C) Fissures that have previously healed but have recurred three or more times.
GUIDELINE NOTE 53, BASIC PERIODONTICS
Line 217
Only for the treatment of severe drug-induced hyperplasia (D4210, D4211). Payable only when there are pockets of 5 mm or greater (D4341).
GUIDELINE NOTE 54, CONDUCT DISORDER
Line 418
Conduct disorder rarely occurs in isolation from other psychiatric diagnoses, the patient should have documented screening (or documented refusal to be screened) for attention deficit/hyperactivity disorder (ADHD); chemical dependency (CD); mood disorders such as anxiety and/or depression; and physical, sexual, and family abuse or other trauma (PTSD).
ICD-10-CM F91.9 (Conduct disorder, unspecified) is included on Line 418 only for children ages 5 and younger who cannot be diagnosed with a more specific mental health diagnosis.
GUIDELINE NOTE 55, PELVIC PAIN SYNDROME
Line 519
A) Diagnostic MRI may be indicated for evaluation of pelvic pain to assess for Adenomyosis and to assist in the management of these challenging patients when all of the following are documented:
1) Patient history of dysmenorrhea, pelvic pain or abnormal uterine bleeding for more than six months with a negative effect on her quality of life.
2) Failure of a six-month therapeutic trial with both of the following (a and b), unless there are contraindications to use:
a) Hormonal therapy (i or ii):
GUIDELINE NOTE 55, PELVIC PAIN SYNDROME (CONT'D)
i) Oral contraceptive pills or patches, progesterone-containing IUDs, injectable hormone therapy, or similar
ii) Agents for inducing amenorrhea (e.g., GnRH analogs or danazol)
b) Nonsteroidal anti-inflammatory drugs
3) An endovaginal ultrasound within the past 12 months that shows no other suspected gynecological pathology if diagnostic MRI shows > 12mm thickening of the junctional zone, the presumptive diagnosis of adenomyosis is fulfilled. See Guideline Note 39.
B) Hysterectomy for chronic pelvic pain in the absence of significant pathology may be Indicated when all of the following are documented (1-7):
1) Patient history of:
a) No treatable conditions or lesions found on laparoscopic examination
b) Pain for more than 6 months with negative effect on patient's quality of life
2) Failure of a six-month therapeutic trial with both of the following (a and b), unless there are contraindications to use:
a) Hormonal therapy (i or ii):
i) Oral contraceptive pills or patches, progesterone-containing IUDs, injectable hormone therapy, or similar
ii) Agents for inducing amenorrhea (e.g., GnRH analogs or danazol)
b) Nonsteroidal anti-inflammatory drugs
3) Evaluation of the following systems as possible sources of pelvic pain:
a) Urinary
b) Gastrointestinal
c) Musculoskeletal
4) Evaluation of the patient's psychologic and psychosexual status for nonsomatic cause of symptoms
5) Nonmalignant cervical cytology, if cervix is present
6) Assessment for absence of endometrial malignancy in the presence of abnormal bleeding
7) Negative preoperative pregnancy test unless patient is postmenopausal or as been previously sterilized
GUIDELINE NOTE 56, NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE
Lines 358,400
Patients seeking care for back pain should be assessed for potentially serious conditions ("red flag" symptoms requiring immediate diagnostic testing), as defined in Diagnostic Guideline D4. Patients lacking red flag symptoms should be assessed using a validated assessment tool (e.g. STarT Back Assessment Tool) in order to determine their risk level for poor functional prognosis based on psychosocial indicators.
For patients who are determined to be low risk on the assessment tool, the following services are included on these lines:
* Office evaluation and education, 
* Up to four total visits, consisting of the following treatments: OMT/CMT, acupuncture, and PT/OT. Massage, if available, may be provided as part of these four total visits.
* First line medications: NSAIDs, acetaminophen, and/or muscle relaxers. Opioids may be considered as a second line treatment, subject to the limitations on coverage of opioids in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE.
For patients who are determined to be medium- or high risk on the validated assessment tool, as well as patients undergoing opioid tapers as in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE, the following treatments are included on these lines:
* Office evaluation, consultation and education 
* Cognitive behavioral therapy. The necessity for cognitive behavioral therapy should be re-evaluated every 90 days and coverage will only be continued if there is documented evidence of decreasing depression or anxiety symptomatology, improved ability to work/function, increased self-efficacy, or other clinically significant, objective improvement.
* Prescription and over-the-counter medications; opioid medications subject to the limitations on coverage of opioids in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE.
GUIDELINE NOTE 56, NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE (CONT'D)
* The following evidence-based therapies, when available, may be provided: yoga, massage when not billed under 97124 and limited to one session per week, Pilates, supervised exercise therapy, intensive interdisciplinary rehabilitation. HCPCS S9451 is only included on Line 400 for the provision of yoga or supervised exercise therapy.
* A total of 30 visits per year of any combination of the following evidence-based therapies when available and medically appropriate. These therapies are only included on these lines if provided by a provider licensed to provide the therapy and when there is documentation of measurable clinically significant progress toward the therapy plan of care goals and objectives using evidence based objective tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
1) Rehabilitative therapy (physical and/or occupational therapy), if provided according to Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES. Rehabilitation services provided under this guideline also count towards visit totals in Guideline Note 6. Massage billed under CPT *97124 is included in this category and is subject to the restrictions on massage in Guideline Note 6.
2) Chiropractic or osteopathic manipulation 
3) Acupuncture
Mechanical traction (CPT *97012) is not included on these lines, due to evidence of lack of effectiveness for treatment of back and neck conditions.
The development of this guideline note was informed by HERC coverage guidances on Low Back Pain Non-Pharmacologic, Non-Invasive Intervention, Low Back Pain, Pharmacological and Herbal Therapies. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 57, PELVIC PHYSICAL THERAPY FOR INTERSTITIAL CYSTITIS
Line 324
Pelvic physical therapy (CPT *97140 and 97161-97164) is included on this line only for treatment of interstitial cystitis in patients who present with pelvic floor tenderness.  Such pelvic PT is only included on this line when provided by professionals trained and experienced 
GUIDELINE NOTE 57, PELVIC PHYSICAL THERAPY FOR INTERSTITIAL CYSTITIS (CONT'D)
in pelvic floor therapy and as limited in Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES.
GUIDELINE NOTE 58, IMPULSE DISORDERS
Line 533
Impulse disorders rarely occur in isolation from other psychiatric diagnosis, thus the Patient should have documented screening for attention deficit/hyperactivity disorder (ADHD); chemical dependency (CD); mood disorders such as anxiety and/or depression; and physical, sexual, and family abuse or other trauma (PTSD).
GUIDELINE NOTE 59, DYSMENORRHEA
Line 544
Hysterectomy for dysmenorrhea may be indicated when all of the following are documented (A-G):
A) Patient history of:
1) No treatable conditions or lesions found on laparoscopic examination
2) Pain for more than 6 months with negative effect on patient's quality of life
B) Failure of a six-month therapeutic trial with both of the following (1 and 2), unless there are contraindications to use:
1) Hormonal therapy (a or b):
a) Oral contraceptive pills or patches, progesterone-containing IUDs, injectable hormone therapy, or similar
b) Agents for inducing amenorrhea (e.g., GnRH analogs or danazol)
2) Nonsteroidal anti-inflammatory drugs
C) Evaluation of the following systems as possible sources of pelvic pain:
1) Urinary
2) Gastrointestinal
3) Musculoskeletal
D) Evaluation of the patient's psychologic and psychosexual status for nonsomatic cause of symptoms
E) Nonmalignant cervical cytology, if cervix is present
F) Assessment for absence of endometrial malignancy in the presence of abnormal bleeding
G) Negative preoperative pregnancy test unless patient is postmenopausal or has been previously sterilized
GUIDELINE NOTE 60, OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE
Lines 343,358,400,517
Opioid medications are only included on these lines under the following criteria. Time periods described below are relative to the patient's initial injury or condition for which opioids were originally prescribed, regardless of whether the individual or any plan paid for the medication. Providers are encouraged to consider the recommendations of the Oregon Opioid Prescribing Guidelines Task Force when prescribing opioid medications: Oregon Acute Opioid Prescribing Guideline (October 2018) and the Oregon Chronic Opioid Prescribing Guidelines (2017-2018).
For acute conditions and flares
During the first 6 weeks after an acute injury, acute flare of chronic pain, or surgery opioid treatment is included on these lines ONLY:
A) When each prescription is limited to 7 days of treatment, AND
B) For short acting opioids only, AND
C) When one or more alternative first line pharmacologic therapies such as NSAIDs, acetaminophen, and muscle relaxers have been tried and found not effective or are contraindicated, AND
D) When prescribed with a plan to keep active (home or prescribed exercise regime) and with consideration of additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, AND
E) There is documented evaluation of the patient's risk factors for opioid misuse or abuse (e.g., history of opioid misuse, verification of prescription history in the PDMP).
During subacute period
Treatment with opioids after 6 weeks of continuous therapy and up to 90 days after the initial injury/flare/surgery is included on these lines ONLY:
A) With documented evidence of improvement of function of at least thirty percent as compared to baseline based on a validated tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
B) When prescribed with a plan to keep active (home or prescribed exercise regime) and additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, when available. 
GUIDELINE NOTE 60, OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE (CONT'D)
C) With verification that the patient is not high risk for opioid misuse or abuse. Such verification may involve
1) Documented verification from the state's prescription monitoring program database that the controlled substance history is consistent with the prescribing record 
2) Use of a validated screening instrument to verify the absence of a current substance use disorder (excluding nicotine) or a history of prior opioid misuse or abuse
3) Administration of a baseline urine drug test to verify the absence of illicit drugs and non-prescribed opioids.
D) Each prescription must be limited to 7 days of treatment and for short acting opioids only
Long-term opioid therapy
Long-term opioid treatment (>90 days) after the initial injury/flare/surgery is included on these lines as described below.
For patients receiving long-term opioid therapy (>90 days) for conditions of the back and spine, continued coverage of opioid medications requires a comprehensive individual treatment plan for chronic pain, taking into account the biological, behavioral, psychological and social factors which may influence each individual's experience of chronic pain as well as any current and past treatments. Treatment plans should be prescribed (unless contraindicated) with a plan to keep active (home or prescribed exercise regimen) and should include additional therapies such as spinal manipulation, physical therapy, yoga or acupuncture unless contraindicated and if available in a patient's community and reasonably accessible to the patient. The treatment plan should conform with the Oregon Chronic Opioid Prescribing Guidelines (2017-2018). A taper plan may be indicated if and when clinically appropriate.
Opioid tapers
Opioid taper plans are not required in order for continued inclusion of long-term opioid therapy on these lines. Providers initiating taper plans are encouraged to follow Oregon Opioid Tapering Guidelines (January 2020). Taper plans should include nonpharmacological 
GUIDELINE NOTE 60, OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE (CONT'D)
treatment strategies for managing the patient's pain. During the taper, behavioral health conditions need to be regularly assessed and appropriately managed.
GUIDELINE NOTE 61, HOSPITALIZATION FOR ACUTE VIRAL INFECTIONS
Lines 140,523,535,539,597
Most acute viral infections are self-limited (e.g. colds, infectious mononucleosis, gastroenteritis). However, some viral infections such as aseptic meningitis, or severe gastroenteritis may require hospitalization to treat the complications of the primary disease.
Accepted coding practices insist that the underlying condition in these cases be the principal diagnosis. For example, complicated viral pneumonia requiring respiratory support with a ventilator would have a principal diagnosis of viral pneumonia and a secondary diagnosis of respiratory failure. Since the diagnosis code for viral pneumonia has historically appeared only on a non-funded line, treatment has not been reimbursable regardless of the severity of the disease. In contrast, the code for viral gastroenteritis appears on Line 146 and any necessary outpatient or inpatient services would be covered. 
Reimbursement for the treatment of certain conditions appearing low on the Prioritized List should be provided in severe cases of the diseases identified on the following four lines.
	Line:	539
	Condition:	OTHER NONINFECTIOUS GASTROENTERITIS AND COLITIS 
	Treatment:	MEDICAL THERAPY 
Treatment of non-infectious gastroenteritis of significant severity that is associated with dehydration should be a covered service if the case fulfills the requirement of hospital admission guidelines using an index of severity of illness.
GUIDELINE NOTE 61, HOSPITALIZATION FOR ACUTE VIRAL INFECTIONS (CONT'D)
	Line:	523
	Condition:	VIRAL, SELF-LIMITING ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS 
	Treatment:	MEDICAL THERAPY 
Treatment of viral encephalitis, myelitis and encephalomyelitis of significant severity that is associated with either obtundation or dehydration should be a covered service if the case fulfills the requirement of hospital admission guidelines using an index of severity of illness.
	Line:	535
	Condition:	ASEPTIC MENINGITIS 
	Treatment:	MEDICAL THERAPY 
Treatment of aseptic meningitis of significant severity that is associated with either obtundation or dehydration should be a covered service if the case fulfills the requirement of hospital admission guidelines using an index of severity of illness.
	Line:	596
	Condition:	ACUTE UPPER RESPIRATORY INFECTIONS AND COMMON COLD 
	Treatment:	MEDICAL THERAPY 
	Line:	597
	Condition:	OTHER VIRAL INFECTIONS
	Treatment:	MEDICAL THERAPY 
	Line:	631
	Condition:	INFECTIOUS DISEASES WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY 
	Treatment:	EVALUATION 
Treatment of acute infectious disease that is associated with respiratory failure, obtundation/altered mental status, or dehydration should be a covered service if the case fulfills the requirement of hospital admission guidelines using an index of severity of illness.
GUIDELINE NOTE 62, NEGATIVE PRESSURE WOUND THERAPY
Lines 8,27,47,79,204,206,234,283,376,422
Negative pressure wound therapy (CPT *97605-97608) is included on these lines only for patients who:
GUIDELINE NOTE 62, NEGATIVE PRESSURE WOUND THERAPY (CONT'D)
* Have wounds that are refractory to or have failed standard therapies;
* Are not suitable candidates for surgical wound closure; or,
* Are at high risk for delayed or non-healing wounds due to factors such as compromised blood flow, diabetic complications, wounds with high risk of fecal contamination, extremely exudative wounds, and similar situations.
GUIDELINE NOTE 63, HYDROCELE REPAIR
Lines 167,531
Excision of hydrocele is only included on Line 167 for children age 18 and younger with hydroceles which persist after 18 months of age. Treatment of hydrocele in men over age 18 is included on Line 167 only when the hydrocele causes pain and functional limitations as assessed and documented by a medical professional.
For children under 18 months of age and men over age 18 who do not meet the above criteria, treatment of hydroceles is included on Line 531.
GUIDELINE NOTE 64, HAMMERTOE SURGERY
Line 164
Hammertoe correction is only included on this line when ALL of the following criteria are met:
A) The patient has diabetes mellitus, AND
B) The patient has a hammertoe with ulcer, pre-ulcerative lesion (including callus), or history of ulcer stemming solely from the hammertoe, AND
C) The patient has not responded adequately to at least 6 months of conservative therapy (for example, NSAIDS, protective cushions, modified footwear, wound care, orthotics) and optimal medical management (for example, adequate diabetic control, smoking cessation), AND
D) The patient has adequate lower extremity vascular perfusion.
Otherwise, hammertoe surgery is included on Line 529.
GUIDELINE NOTE 65, SEVERE CYSTIC ACNE
Lines 451,509
Acne is only included on Line 451 if it is severe, defined as the presence of the following characteristics: persistent or recurrent inflammatory nodules and cysts AND ongoing scarring. Otherwise, acne diagnoses are included on Line 509.
Note that acne with recurrent abscesses or communicating sinuses is covered according to Guideline Note 132 ACNE CONGLOBATA AND ACNE FULMINANS.
GUIDELINE NOTE 66, CERVICAL DYSPLASIA
Line 25
Work up and treatment of cervical dysplasia should follow the American Society for Cervical Colposcopy and Pathology guidelines as published in the Journal of Lower Genital Tract Disease, April 2020. See https://pmc.ncbi.nlm.nih.gov/articles/PMC7147428/pdf/lgt-24-102.pdf, retrieved on 10/8/24, referencing the 2019 ASCCP Risk-Based Management Consensus Guidelines.
GUIDELINE NOTE 67, BROW PTOSIS
Lines 309,390,470,634
Brow ptosis repair is included on Line 390 for congenital brow ptosis in children only when ALL the following criteria are met:
A) The condition developed within the first year of life, and
B) Ptosis interferes with field of vision, and
C) The child has abnormal head posture (e.g., head tilt or turn, chin up or chin down), amblyopia or strabismus or is at high risk for development of amblyopia.
Brow ptosis repair is included on Line 470 for acquired brow ptosis only when ALL the following criteria are present:
A) Brow ptosis is causing a functional impairment of upper/outer visual fields with documented complaints of interference with vision or visual field related activities such as difficulty reading or driving due to upper brow drooping, looking through eyelashes, or seeing the upper eyelid skin, and
B) Photographs show the eyebrow below the supraorbital rim, and
GUIDELINE NOTE 67, BROW PTOSIS (CONT'D)
C) Overhanging skin due to brow ptosis is sufficiently low to produce a visually significant field restriction of approximately 30 degrees or less from fixation or a central "pseudo-margin to reflex distance" of 2.0 mm or less, and
D) The visual field impairment cannot be corrected by an upper lid blepharoplasty alone.
Otherwise, brow ptosis repair is included on Line 634.
GUIDELINE NOTE 68, TREATMENT OF CHRONIC LOWER EXTREMITY VENOUS DISEASE 
Lines 376,507,621
Medical treatment of chronic lower extremity venous disease with major complications (skin ulceration, recurrent cellulitis or clinically significant bleeding) is included on Line 376, including medical compression garments.
Surgical treatment of chronic lower extremity venous disease is only included on Line 376 when:
A) The patient has had an adequate 3-month trial of conservative therapy and failed; AND
B) Ultrasound findings of severe axial venous reflux (>1 second in the greater or small saphenous vein or accessory saphenous vein; AND
C) The patient has one of the following:
1) Non-healing skin ulceration in the area of the varicose vein(s), OR
2) Recurrent episodes of cellulitis associated with chronic venous disease OR
3) Clinically significant bleeding from varicose vein(s).
Otherwise, these diagnoses are included on Lines 507 and 621.
GUIDELINE NOTE 69, ELECTROCONVULSIVE THERAPY (ECT)
Lines 7,22,26
Electroconvulsive therapy (ECT; CPT *90870) is included on these lines for the treatment of major depressive disorder, bipolar disorder, schizophrenic disorder, or schizoaffective disorder when one or more of the following conditions are present:
1) Acute suicidality with high risk of acting out suicidal thoughts
2) Psychotic features
3) Rapidly deteriorating physical status due to complications from the depression, such as poor oral intake
GUIDELINE NOTE 69, ELECTROCONVULSIVE THERAPY (ECT) (CONT'D)
4) Catatonia
5) History of poor response to multiple adequate trails of medications and/or combination treatments, or the patient is unable or unwilling to comply with or tolerate side effects of available medications, or has a co-morbid medical condition that prevents the use of available medications
6) History of good response to ECT during an earlier episode of the illness
7) The patient is pregnant and has severe mania or depression, and the risks of providing no treatment outweigh the risks of providing ECT
The frequency and number of treatments need to be determined by the severity of illness and by the relative benefits and risks of ECT treatment. During the course of ECT, it is important to monitor therapeutic responses and adverse effects of treatment. Continuation treatment of patients who have responded to ECT consists of treatment with antidepressant medications and/or a tapering schedule of ECT treatments. Continuation treatment reduces the risk of relapse and should be offered to all patients who respond to ECT. Continuation ECT treatments should be tapered and discontinued as the patient's clinical condition allows. Maintenance treatment with ECT is indicated to prevent recurrence of depression in patients whose remission of symptoms cannot be maintained with pharmacologic antidepressant treatment.
GUIDELINE NOTE 70, TWELVE-MONTH CONTRACEPTIVE DISPENSING
Line 6
Twelve-month contraceptive prescription dispensing is included on this line and could include 14-month coverage for those selecting continuous use of contraceptives.
GUIDELINE NOTE 71, HIP RESURFACING
Line 353
Hip resurfacing is a covered service for patients who are likely to outlive a traditional prosthesis and who would otherwise require a total hip replacement, and should only be done by surgeons with specific training in this technique.
The following criteria are required to be met for coverage of this procedure:
GUIDELINE NOTE 71, HIP RESURFACING (CONT'D)
A) The diagnosis of osteoarthritis or inflammatory arthritis
B) Failure of nonsurgical management
C) The device must be FDA approved
Patients who are candidates for hip resurfacing must not be:
A) Patients with active or suspected infection in or around the hip joint, or sepsis
B) Patients who are skeletally immature 
C) Patients with any vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery 
D) Patients with bone stock inadequate to support the device, including severe osteopenia or a family history of severe osteoporosis or osteopenia 
E) Patients with osteonecrosis or avascular necrosis with >50% involvement of the femoral head 
F) Patients with multiple cysts of the femoral head 
G) Females of childbearing age 
H) Patients with known moderate-to-severe renal insufficiency 
I) Patients who are immunosuppressed with diseases such as AIDS or persons receiving high doses of corticosteroids 
J) Patients who are severely overweight 
K) Patients with known or suspected metal sensitivity
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 72, CONGENITAL UROLOGIC CONDITIONS
Lines 86,93,432,638
The following conditions are included on these Lines 86, 93 and 432 only for children aged 18 and younger.  For adults, these conditions are included on Line 638.
* ICD-10-CM Q54.0 (Hypospadias, balanic) 
* ICD-10-CM Q55.22 (Retractile testicle) 
* ICD-10-CM Q60.3 (Renal hypoplasia, unilateral)
* ICD-10-CM Q62.4 (Agenesis of ureter)
* ICD-10-CM Q62.5 (Duplication of ureter)
* ICD-10-CM Q62.60 (Accessory kidney)
* ICD-10-CM Q62.61 (Deviation of ureter)
GUIDELINE NOTE 72, CONGENITAL UROLOGIC CONDITIONS (CONT'D)
* ICD-10-CM Q62.62 (Displacement of ureter)
* ICD-10-CM Q63 (Other congenital malformations of kidney)
GUIDELINE NOTE 73, PENILE ANOMALIES
Lines 422,432,558,638
Congenital anomalies of the penis (ICD-10-CM Q54.4, Q55.5 and Q55.6) are included on Line 432 only when they:
A) Are associated with hypospadias, OR
B) Result in documented urinary retention, OR
C) Result in repeated urinary tract infections, OR
D) Result in recurrent infections such as meatitis or balanitis, OR
E) Involve 35 degrees of curvature or greater for conditions resulting in lateral or ventral curvature, OR
F) Involve 60 degrees of rotation or greater for conditions resulting in penile torsion, OR
G) Involve aplasia/congenital absence of the penis.
Otherwise, these diagnoses are included on Line 638.
Acquired anomalies of the penis (ICD-10-CM N48.82, N48.83, N48.89 or T81.9XXA) are included on Line 422 only when they are the result of a prior penile procedure AND either:
A) Result in a skin bridge, OR
B) Result in a buried penis, OR
C) Are associated with hypospadias, OR
D) Result in documented urinary retention, OR
E) Result in repeated urinary tract infections, OR
F) Result in recurrent infections such as meatitis or balanitis, OR
G) Involve 35 degrees of curvature or greater for conditions resulting in lateral or ventral curvature, OR
H) Involve 60 degrees of rotation or greater for conditions resulting in penile torsion.
Otherwise, these diagnoses are included on Line 558 or Line 638.
GUIDELINE NOTE 74, GROWTH HORMONE TREATMENT
Lines 40,383,632
Treatment with growth hormone for ICD-10-CM E23.0 (Hypopituitarism) is included on Lines 40 and 383 for adults when:
A) Prescribed by or in consultation with an endocrinologist; AND
B) Either
1) Growth hormone deficiency is confirmed by a negative response to a growth hormone stimulation test (e.g., serum GH levels of <5 ng/mL on stimulation testing with either of the following: glucagon or insulin); OR
2) Patient has had the pituitary removed or destroyed or has had panhypopituitarism since birth; AND 
C) The prescriber certifies that the growth hormone is not being prescribed for anti-aging therapy or to enhance athletic ability or body building
ICD-10-CM E23.0 is included on Line 632 only for adult human growth hormone deficiency that does not meet the above criteria.
Treatment of children and adolescents with growth hormone (for any indication) must be evaluated for medical appropriateness and medical necessity on a case-by-case basis. Therapy must be initiated by and continued in consultation with a pediatric endocrinologist.
GUIDELINE NOTE 75, APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER
Line 192
Applied behavioral analysis (ABA), including early intensive behavioral intervention (EIBI), represented by CPT codes 97151-97158, is included on Line 192 AUTISM SPECTRUM DISORDERS for the treatment of autism spectrum disorders.
ABA services are provided in addition to any rehabilitative services (e.g. physical therapy, occupational therapy, speech therapy) included in Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES that are indicated for other acute qualifying conditions.
Individuals ages 1-12
Intensive interventions
Specifically, EIBI (for example, UCLA/Lovaas or Early Start Denver Model), is included on this line.
GUIDELINE NOTE 75, APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER (CONT'D)
For a child initiating EIBI therapy, EIBI is included for up to six months. Ongoing coverage is based on demonstrated progress towards meaningful predefined objectives (objectives should be achieved as a result of the EIBI, over and beyond gains that would be expected to arise from maturation alone) using a standardized, multimodal assessment, no more frequently than every six months. Examples of such assessments include Vineland, IQ tests (Mullen, WPPSI, WISC-R), language measures, behavior checklists (CBCL, ABC), and autistic symptoms measures (SRS).
The evidence does not lead to a direct determination of optimal intensity. Studies of EIBI ranged from 15-40 hours per week. Through Oregon's Senate Bill 365, other payers are mandated to cover a minimum of 25 hours per week of ABA. There is no evidence that increasing intensity of therapy yields improves outcomes. Studies for these interventions had a duration from less than one year up to 3 years.
Less intensive ABA-based interventions
If EIBI is not indicated, has been completed, or there is not sufficient progress toward multidimensional goals, then less intensive ABA-based interventions (such as parent training, play/interaction-based interventions, and joint attention interventions) are included on this line to address core symptoms of autism and/or specific problem areas. Initial coverage is provided for six months. Ongoing coverage is based on demonstrated progress towards meaningful predefined objectives, with demonstration of medical appropriateness and/or emergence of new problem behaviors.
Effective interventions from the research literature had lower intensity than EIBI, usually a few hours per week to a maximum of 16 hours per week, divided into daily, twice daily or weekly sessions, over a period of several months.
Parent/caregiver involvement
Parent/caregiver involvement and training is recommended as a component of treatment.
GUIDELINE NOTE 75, APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER (CONT'D)
Individuals ages 13 and older
Intensive ABA is not included on this line.
Targeted ABA-based behavioral interventions to address problem behaviors, are included on this line. The quality of evidence is insufficient to support these interventions in this population. However, due to strong caregiver values and preferences and the potential for avoiding suffering and expense in dealing with unmanageable behaviors, targeted interventions may be reasonable. Behaviors eligible for coverage include those which place the member at risk for harm or create significant daily issues related to care, education, or other important functions. Ongoing coverage is based on demonstrated progress towards meaningful predefined objectives, with demonstration of medical appropriateness and/or emergence of new problem behaviors.
Very low-quality evidence is available to illustrate needed intensity and duration of intervention. In the single-subject research design literature, frequency and duration of interventions were highly variable, with session duration ranging from 30 seconds to 3 hours, number of sessions ranging from a total of three to 8 times a day, and duration ranging from 1 to 20 weeks. These interventions were often conducted in inpatient or residential settings and studies often included patients with intellectual disabilities, some of which were not diagnosed with autism.
Parent/caregiver involvement and training is encouraged.
GUIDELINE NOTE 76, DIAGNOSTIC TESTING FOR LIVER FIBROSIS TO GUIDE MANAGEMENT IN CHRONIC LIVER DISEASE
Line 197
The following tests are included on this line because of their ability to effectively distinguish F4 from lower levels of fibrosis:
   Non-proprietary blood tests:
* Platelet count
* Hyaluronic acid
* Age-platelet index
* AST-platelet ratio
GUIDELINE NOTE 76, DIAGNOSTIC TESTING FOR LIVER FIBROSIS TO GUIDE MANAGEMENT IN CHRONIC LIVER DISEASE (CONT'D)
* FIB-4
* FibroIndex
* Forns index
* GUCI
* Lok index
   Proprietary blood test:
* Enhanced Liver Fibrosis (ELF(tm)) for patients with indeterminate or high FIB-4 score when liver elastography is not available
   Imaging tests:
* Transient elastography (FibroScan(r))
* Acoustic radiation force impulse imaging (ARFI) (Virtual Touch(tm) tissue quantification, ElastPQ)
* Shear wave elastography (SWE) (Aixplorer(r))
The following tests are not included on this line (or any other line):
   Real time tissue elastography
   Proprietary blood tests such as:
* Fibrometer(tm)
* FirbroTest(r)
* Hepascore(r)
* FIBROSpect(r) II
Noninvasive tests for liver fibrosis are only indicated for the initial assessment or when monitoring progression from F3 to F4, no more than annually.
Magnetic resonance elastography is included on this line for patients when ALL of the following apply:
* In whom at least one imaging test (FibroScan, ARFI, and SWE) has resulted in indeterminant results, a second one is similarly indeterminant, contraindicated or unavailable
* The patient is suspected to have aggressive disease/advanced fibrosis (e.g., in NAFLD based on older age, diabetes, obesity, high FIB-4, or APRI)
GUIDELINE NOTE 76, DIAGNOSTIC TESTING FOR LIVER FIBROSIS TO GUIDE MANAGEMENT IN CHRONIC LIVER DISEASE (CONT'D)
* Cirrhosis is not identified on routine imaging (ultrasound, CT)
* A liver biopsy would otherwise be indicated, but MRE would be an appropriate alternative.
Repeat MR Elastography is not indicated.
GUIDELINE NOTE 77, TIPS PROCEDURE
Lines 56,215,278,331
TIPS procedure (CPT code 37182, 37183) is included on these lines for patients who:
A) Have failed sclerotherapy and have acute bleeding from varices; or
B) Have failed sclerotherapy and have had 2 or more episodes of re-bleeding requiring a transfusion during a 2-week period; or
C) Requires bleeding control from varices and surgery is contraindicated; or
D) Are liver transplant candidates who require bleeding control from varices; or
E) Have severe debilitating ascites or hepatic hydrothorax refractory to medical management (e.g., oral diuretics and repeated large-volume paracentesis).
GUIDELINE NOTE 78, HEPATIC METASTASES
Line 312
Hepatectomy/resection (CPT *47120, 47122, 47125 or 47130) of hepatic metastases (ICD-10-CM C22.9 or C78.7) are included on this line only when there are no extrahepatic metastases.
Microwave and radiofrequency ablation and cryoablation (CPT *37243, 47340, 47370, 47371, 47380-47383, 47389) are included on this line only when ALL of the following criteria are met:
A) Treatment is for colorectal cancer liver metastases, functioning neuroendocrine tumors or hepatocellular cancer; AND
B) There are no extrahepatic metastases; AND
C) The patient is not a candidate for open surgical resection due to the location or extent of the liver disease or due to co-morbid conditions such that the member is unable to tolerate an open surgical resection; AND
D) All tumors in the liver, as determined by pre-operative imaging, would be potentially destroyed by cryotherapy, microwave, or radiofrequency ablation; AND
GUIDELINE NOTE 78, HEPATIC METASTASES (CONT'D)
E) Liver lesions must be 4 cm or less in diameter and occupy less than 50% of the liver parenchyma.
Yttrium-90 therapy (CPT *79445) is only covered for treatment of hepatocellular carcinoma as specified in GUIDELINE NOTE 185, YTTRIUM-90 THERAPY.
GUIDELINE NOTE 79, BREAST RECONSTRUCTION
Line 190
Breast reconstruction is only covered after mastectomy, or lumpectomy that results in a significant deformity or asymmetry, as a treatment for breast cancer or as prophylactic treatment for the prevention of breast cancer in a woman who qualifies under Guideline Note 3, and must be completed within 5 years of initial mastectomy or lumpectomy.
Breast reconstruction may include contralateral reduction mammoplasty (CPT *19318) or contralateral mastopexy (CPT *19316). Mastopexy is only to be covered when contralateral reduction mammaplasty is inappropriate for breast reconstruction and mastopexy will accomplish the desired reconstruction result.
GUIDELINE NOTE 80, REPAIR OF NOSE TIP
Line 298
Nose tip repair (CPT *30460) is included on this line only to be used in conjunction with codes 40700, 40701, 40702 or 40720. If not done in the context of a larger cleft palate/lip surgery, then nose tip repair is only included on this line if required for correction of physical functioning.
GUIDELINE NOTE 81, BUERGER'S DISEASE
Lines 234,633
Buerger's disease (ICD-10-CM I73.1) is included on Line 234 only when ulceration or gangrene is present. Otherwise, this diagnosis is included on Line 633. ICD-10-CM I73.1 does not pair on Line 234 with revascularization procedures, bypass graft procedures, or angioplasty.
GUIDELINE NOTE 82, EARLY INTERVENTION FOR PSYCHOSIS
Lines 22,26,275
These lines include "early intervention for psychosis," a multidisciplinary specialty team-based intervention that includes:
A) Psychiatric medication management
B) Individual counseling
C) Family group therapy
D) Family individual therapy
The goal of the early intervention is to minimize harms of a first outbreak of psychosis and improve long-term functioning.
GUIDELINE NOTE 83, HIP CORE DECOMPRESSION
Line 353
Hip Core Decompression (S2325) is covered only for early/pre-collapse (stage I or II; before X-ray changes are evident) avascular necrosis of the hip (femoral head and/or neck).
GUIDELINE NOTE 84, MEDICAL NUTRITION THERAPY FOR EPILEPSY
Line 30
Medical Nutrition Therapy (CPT *97802-97804) is included on this line only for training in the ketogenic diet for children with epilepsy in cases where the child has failed or not tolerated conventional therapy.
GUIDELINE NOTE 85, ELECTIVE INDUCTION OF LABOR
Line 1
Induction of labor is covered for:
* Gestational age beyond 41 weeks 0 days
* Prelabor rupture of membranes, term
* Fetal demise
* Preeclampsia, term (severe or mild)
* Eclampsia
* Chorioamnionitis
* Diabetes, pre-existing and gestational
* Placental abruption
GUIDELINE NOTE 85, ELECTIVE INDUCTION OF LABOR (CONT'D)
* Preeclampsia, preterm (severe or mild)
* Severe preeclampsia, preterm
* Cholestasis of pregnancy
* Preterm, prelabor rupture of membranes; 
* Gastroschisis
* Twin gestation
* Maternal medical conditions (e.g., renal disease, chronic pulmonary disease, chronic hypertension, cardiac disease, antiphospholipid syndrome)
* Gestational hypertension
* Fetal compromise (e.g. isoimmunization, oligohydramnios)
* Intrauterine growth restriction/Small for gestational age, term
* Elective purposes, >39 weeks 0 days to <41 weeks 0 days (without a medical or obstetrical indication) with a favorable cervix (for example, with a Bishop score 6 or greater)
Induction of labor is not covered for the following:
* Macrosomia (in the absence of maternal diabetes)
* Elective purposes, >39 weeks 0 days to <41 weeks 0 days (without a medical or obstetrical indication) with an unfavorable cervix (for example, a Bishop score <6)
* Elective purposes <39 weeks (without a medical or obstetrical indication)
* Intrauterine growth restriction/Small for gestational age, preterm (without other evidence of fetal compromise)
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 86, ORGANIC MENTAL DISORDERS
Line 200
There is limited evidence of the effectiveness of mental health treatment of organic mental disorders. However, case management can be critical. Effective treatments may be available for co-morbid conditions such as mood disorders. When treating co-morbid conditions associated with organic mental disorder, those conditions should be the primary diagnosis for 
GUIDELINE NOTE 86, ORGANIC MENTAL DISORDERS (CONT'D)
billing purposes. The treatment of co-morbid mental health conditions should be consistent with the treatment methods, frequency, and duration normally applied to those diagnoses. Treatment of neurologic dysfunctions that may be seen in individuals with organic mental disorder are prioritized according to the four dysfunction lines found on the Prioritized List (Lines 71, 290, 342 and 374).
GUIDELINE NOTE 87, INFLUENZA
Line 397
Treatment and post-exposure prophylaxis of influenza should comply with state and national public health recommendations.
GUIDELINE NOTE 88, USE OF PROGESTERONE CONTAINING IUDS FOR NON-CONTRACEPTIVE INDICATIONS
Lines 190,421,468
Intrauterine device (IUD) insertion and removal (CPT *58300 and 58301) are included on these lines for use only with progesterone-containing IUDs. These CPT codes are covered only for:
A) menorrhagia (ICD-10-CM N92.0-N92.2 and N92.4)
B) for uterine protection in women taking estrogen replacement therapy after premature ovarian failure (ICD-10-CM E28.310, E28.319, E28.39, E28.8, E28.9) or menopause (ICD-10-CM N95.1) ; and 
C) for uterine protection in women taking selective estrogen receptor modulators (SERMs).
GUIDELINE NOTE 89, REVASCULARIZATION FOR CHRONIC STABLE ANGINA
Line 188
Coronary revascularization with percutaneous coronary intervention (PCI; CPT *92920-92944) or coronary artery bypass surgery (CABG; CPT *33510-33516, 33517-33530, 33533-33536) is included on this line for patients with stable angina (ICD-10-CM I20, I25.111-119, I25.701-9, I25.711-9, I25.721-9, I25.731-9, I25.751-9, I25.761-9, I25.791-9,I25.89, I25.9) whose symptoms are not controlled with optimal medical therapy for angina or who cannot tolerate such therapy.
GUIDELINE NOTE 89, REVASCULARIZATION FOR CHRONIC STABLE ANGINA (CONT'D)
Optimal medical therapy for angina symptom control is defined as two or more antianginals (beta-blocker, nitrate, calcium channel blocker, or ranolazine) in addition to standard treatment for coronary artery disease.
For those with left main coronary artery stenosis or three-vessel coronary artery stenosis, CABG is included on this line with or without a trial of optimal medical therapy.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 90, COGNITIVE REHABILITATION
Lines 91,177,195,283,314
Once physical stabilization from acute brain injury has occurred, as determined by an attending physician, cognitive rehabilitation (CPT *97129 and 97130) is included on this line for a three-month period. This three-month period does not have to be initiated immediately following stabilization from the injury. For up to 3 years following the acute event, an additional 6 visits of cognitive rehabilitation are included on this line each time the patient has a major change in status resulting in a significantly improved prognosis. Cognitive rehabilitation is not included on this line for those in a vegetative state or for those who are unable or unwilling to participate in therapy.
GUIDELINE NOTE 91, CARIES ARRESTING MEDICAMENT APPLICATION
Line 340
CDT **D1354/CPT *0792T, when used to represent silver diamine fluoride applications for the treatment (rather than prevention) of caries, is limited to a maximum of two applications per year.
CDT **D1354/CPT *0792T are also included on this line to:
A) arrest or reverse noncavitated carious lesions on occlusal surfaces using sealants plus 5% fluoride varnish (application every 3-6 months) or sealants alone (application every 3-6 months), 1.23% fluoride gel (application every 3-6 months), resin infiltration plus 5% fluoride varnish (application every 3-6 months), or 0.2% fluoride mouth rinse (once per week).
GUIDELINE NOTE 91, CARIES ARRESTING MEDICAMENT APPLICATION (CONT'D)
B) arrest or reverse noncavitated carious lesions on approximal surfaces using 5% fluoride varnish (application every 3-6 months), resin infiltration alone, resin infiltration plus 5% fluoride varnish (application every 3-6 months), or sealants alone.
C) arrest or reverse noncavitated carious lesions on facial or lingual surfaces using 1.23% fluoride gel (application every 3-6 months) or 5% fluoride varnish (application every 3-6 months).
GUIDELINE NOTE 92, ACUPUNCTURE
Lines 1,4,5,62,65,92,111,112,114,125,129,133,135,157,158,190,198-200,207,209,213,214,228,233,236,237,256,257,260,269,274,284,285,292,311-313,326,339,358,393,394,400,408,417,433,462,527,545
Inclusion of acupuncture (CPT *97810-97814) on the Prioritized List has the following limitations:
Line 1 PREGNANCY
      Acupuncture pairs on Line 1 for the following conditions and codes.
          Hyperemesis gravidarum 
      ICD-10-CM: O21.0, O21.1
Acupuncture pairs with hyperemesis gravidarum when a diagnosis is made by the maternity care provider and referred for acupuncture treatment for up to 12 sessions of acupressure/acupuncture per pregnancy.
          Breech presentation
      ICD-10-CM: O32.1
Acupuncture (and moxibustion) is paired with breech presentation when a referral with a diagnosis of breech presentation is made by the maternity care provider, the patient is between 33- and 38-weeks gestation, for up to 6 session per pregnancy.
          Back and pelvic pain of pregnancy
      ICD-10-CM: O99.89
Acupuncture is paired with back and pelvic pain of pregnancy when referred by maternity care provider/primary care provider for up to 12 sessions per pregnancy.
GUIDELINE NOTE 92, ACUPUNCTURE (CONT'D)
Line 4 SUBSTANCE USE DISORDER,Line 62 SUBSTANCE-INDUCED MOOD, ANXIETY, DELUSIONAL AND OBSESSIVE-COMPULSIVE DISORDERS,Line 65 SUBSTANCE-INDUCED DELIRIUM; SUBSTANCE INTOXICATION AND WITHDRAWAL
Acupuncture is included on these lines only when used as part of a documented broader treatment plan that offers patients a variety of evidence-based interventions including behavioral interventions, social support, and Medication Assisted Treatment (MAT), as appropriate.
Line 5 TOBACCO DEPENDENCE
Acupuncture is included on this line for a maximum of 12 sessions per quit attempt up to two quit attempts per year; additional sessions may be authorized if medically appropriate.
Lines 92, 111, 112, 114, 125, 129, 133, 135, 157, 158, 190, 198, 199, 207, 209, 213, 214, 228, 233, 236, 237, 256, 257, 259, 260, 269, 274, 284, 285, 292, 311, 312, 313, 326, 339, 369, 393, 394, 417, 433 and 545
Acupuncture is paired only with the ICD-10 code G89.3 (Neoplasm related pain (acute) (chronic)) when there is active cancer and limited to 12 total sessions per year; patients may have additional visits authorized beyond these limits if medically appropriate.
Line 200 CHRONIC ORGANIC MENTAL DISORDERS INCLUDING DEMENTIAS 
Acupuncture is paired with the treatment of post-stroke depression only (ICD-10-CM F06.31 or F06.32). Treatments may be billed to a maximum of 30 minutes face-to-face time and limited to 12 total sessions per year, with documentation of meaningful improvement; patients may have additional visits authorized beyond these limits if medically appropriate.
 Line 358 SCOLIOSIS 
Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE.
Line 400 CONDITIONS OF THE BACK AND SPINE 
Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE.
Line 408 MIGRAINE AND TENSION HEADACHES
GUIDELINE NOTE 92, ACUPUNCTURE (CONT'D)
Acupuncture pairs on Line 408 for migraine (ICD-10-CM G43.0, G43.1, G43.5, G43.7, G43.8, G43.9), for up to 12 sessions per year.
Line 462 OSTEOARTHRITIS AND ALLIED DISORDERS
      Acupuncture pairs on Line 462 for osteoarthritis of the knee only (ICD-10-CM M17), for up to 12 sessions per year.
*Line 527 TENSION HEADACHES
Acupuncture is included on Line 527 for treatment of tension headaches (ICD-10-CM G44.2), for up to 12 sessions per year.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
*Below the current funding line.
GUIDELINE NOTE 93, ENDOBRONCHIAL VALVES
Line 281
Endobronchial valves (CPT *31647-31649 and 31651) are only included on this line when ALL of the following criteria are met:
A) The patient has severe heterogenous or homogenous emphysema
1) Severe emphysema is demonstrated by pulmonary function testing showing
a) Forced expiratory volume in one second (FEV 1) less than or equal to 45% predicted and, if age 70 or older, FEV 1 less than or equal to 15% predicted value
b) Total lung capacity (TLC) less than or equal to 100% predicted post-bronchodilator
c) Residual volume (RV) less than or equal to 150% predicted post-bronchodilator 
B) The patient has significant hyperinflation in regions of the lung that have too little to no collateral ventilation
C) The patient is receiving optimized medical care
D) The patient is stable with less than or equal to 20 mg prednisone (or equivalent) dose a day
GUIDELINE NOTE 93, ENDOBRONCHIAL VALVES (CONT'D)
E) The patient has participated in pulmonary rehabilitation and has a post-rehabilitation 6-minute walk of 140 meters or farther
F) The patient is a non-smoker as determined by the performing provider
GUIDELINE NOTE 94, PECTUS EXCAVATUM
Lines 399,515
Pectus excavatum (ICD-10-CM Q67.6) is included on Line 399 only for patients with all of the following:
A) Severe deformity (Haller index >3.25) AND
B) Documented pulmonary or cardiac dysfunction demonstrated by either
1) Cardiac effects to include cardiac compression or displacement, bundle branch block or other cardiac pathology secondary to compression of the heart, OR
2) Pulmonary function studies demonstrating at least a moderately severe restrictive lung defect, AND
C) these conditions are reasonably expected to be relieved with surgery.
Otherwise, this condition is included on Line 515
ICD-10-CM Q79.8 is included on Line 399 only for Poland syndrome.  Other diagnoses using this code are on Line 515.  Surgical reconstruction of musculo-skeletal chest wall deformities associated with Poland's syndrome are only included on Line 399 when causing functional deficits.
GUIDELINE NOTE 95, IMPLANTABLE CARDIAC DEFIBRILLATORS
Lines 97,98,110,279,283
Implantable cardiac defibrillators are included on these lines for patients with one or more of the following:
A) Patients with a personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation. Patients must have demonstrated one of the following: 
1) Documented episode of cardiac arrest due to ventricular fibrillation (VF), not due to a transient or reversible cause 
GUIDELINE NOTE 95, IMPLANTABLE CARDIAC DEFIBRILLATORS (CONT'D)
2) Documented sustained ventricular tachyarrhythmia (VT), either spontaneous or induced by an electrophysiology (EP) study, not associated with an acute myocardial infarction
B) Patients with a prior myocardial infarction and a measured left ventricular ejection fraction (LVEF) 0.30 or less. Patients must not have:
1) New York Heart Association (NYHC) classification IV heart failure; or
2) Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; or
3) Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary intervention (PCI) with angioplasty and/or stenting, within past 3 months; or
4) Had a myocardial infarction in the past 40 days; or
5) Clinical symptoms or findings that would make them a candidate for coronary revascularization
C) Patients who have severe ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation, and have New York Heart Association (NYHA) Class II or III heart failure, left ventricular ejection fraction (LVEF) 35% or less. Additionally, patients must not have:
1) Had a coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) with angioplasty and/or stenting, within the past 3 months; or
2) Had a myocardial infarction within the past 40 days; or
3) Clinical symptoms and findings that would make them a candidate for coronary revascularization.
D) Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation, and have New York Heart Association (NYHA) Class II or III heart failure, left ventricular ejection fraction (LVEF) 35% or less, been on optimal medical therapy (OMT) for at least 3 months. Additionally, patients must not have:
1) Had a coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) with angioplasty and/or stenting, within the past 3 months; or
2) Had a myocardial infarction within the past 40 days; or
3) Clinical symptoms and findings that would make them a candidate for coronary revascularization.
E) Patients with documented familial, or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained ventricular tachycardia or ventricular fibrillation), to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy.
GUIDELINE NOTE 95, IMPLANTABLE CARDIAC DEFIBRILLATORS (CONT'D)
F) Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, elective replacement indicator (ERI) or device/lead malfunction.
For these patients identified in A-E, a formal shared decision-making encounter must occur between the patient and a physician or qualified non-physician practitioner using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision-making encounter may occur at a separate visit.
All indications above in A-F must meet the following criteria:
A) Patients must be clinically stable (e.g., not in shock, from any etiology);
B) Left ventricular ejection fraction (LVEF) must be measured by echocardiography, radionuclide (nuclear medicine) imaging, or catheter angiography;
C) Patients must not have significant contraindications
Exceptions to waiting periods for patients that have had a coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) with angioplasty and/or stenting, within the past 3 months, or had a myocardial infarction within the past 40 days:
A) Cardiac Pacemakers: Patients who meet all CMS coverage requirements for cardiac pacemakers and who meet the criteria in this guideline for an ICD may receive the combined device in one procedure at the time the pacemaker is clinically indicated;
B) Replacement of ICDs: Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, elective replacement indicator (ERI) or device/lead malfunction.
Other Indications:
For patients who are candidates for heart transplantation on the United Network for Organ Sharing (UNOS) transplant list awaiting a donor heart, ICDs are only included on these lines as a bridge to transplant to prolong survival until a donor becomes available.
GUIDELINE NOTE 96, TREATMENT OF BENIGN NEOPLASM OF URINARY ORGANS
Lines 213,500
Treatment of benign urinary system tumors (ICD-10-CM D17.71, D30.00-D30.02) are included on Line 213 with evidence of bleeding or urinary obstruction. Treatment of 1) oncocytoma 
GUIDELINE NOTE 96, TREATMENT OF BENIGN NEOPLASM OF URINARY ORGANS (CONT'D)
which is >5 cm in size or symptomatic and 2) angiomyolipoma (AML) which is >5cm in women of childbearing age or in symptomatic men or women is covered. Otherwise, these diagnoses are included on Line 500.
GUIDELINE NOTE 97, MANAGEMENT OF ACROMIOCLAVICULAR JOINT SPRAIN
Lines 415,591
Sprain of acromioclavicular joint (ICD-10-CM S43.50-S43.52) is only included on Line 415 for Grade 4-6 sprains. Surgical management of these injuries is covered only after a trial of conservative therapy. Grade 1-3 acromioclavicular joint sprains are included only on Line 591.
GUIDELINE NOTE 98, SIGNIFICANT INJURIES TO LIGAMENTS, TENDONS AND MENISCI
Lines 373,415,430,591
Significant injuries to ligaments, tendons and/or menisci are those that result in clinically demonstrable joint instability or mechanical interference with motion. Significant injuries are covered on Line 373, Line 415, or Line 430 for both medical and surgical interventions. Non-significant injuries are included on Line 591.
Iliotibial (IT) band syndrome (ICD10 M76.3) is included on Line 373 only for pairing with 2 physical therapy visits with a provider licensed to provide physical therapy services, anti-inflammatory medications, and primary care office visits. Otherwise, it is included on Line 591.
GUIDELINE NOTE 99, ROUTINE PRENATAL ULTRASOUND
Lines 1,35,37,63
Routine ultrasound for the average risk pregnant woman is included on these lines for:
A) One ultrasound in the first trimester for the purpose of identifying fetal aneuploidy or anomaly (between 11 and 13 weeks of gestation) and /or dating confirmation. In some instances, if a patient's LMP is truly unknown, a dating ultrasound may be indicated prior to an aneuploidy screen
B) One ultrasound for the purpose of anatomy screening after 18 weeks gestation. For those using tobacco during pregnancy, additional counseling around smoking impacts on the fetus is included during this ultrasound.
GUIDELINE NOTE 99, ROUTINE PRENATAL ULTRASOUND (CONT'D)
Only one type of routine prenatal ultrasound should be covered in a single day (i.e., transvaginal or abdominal).
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 100, SMOKING AND SPINAL FUSION
Lines 47,150,199,252,343,358,399,474,517,545
Non-emergent spinal arthrodesis (CPT *22532-22634) is limited to patients who are non-smoking and abstinent from all nicotine products for 6 weeks prior to the planned procedure, as shown by a negative cotinine urine or serum test (less than or equal to 20 ng/mL). Patients should be given access to appropriate smoking cessation therapy. Non-emergent spinal arthrodesis is defined as surgery for a patient with a lack of myelopathy or rapidly declining neurological exam.
GUIDELINE NOTE 101, ARTIFICIAL DISC REPLACEMENT
Lines 343,517
Artificial disc replacement (CPT *22856-22859; 22861-22865) is included on Line 343 as an alternative to fusion for patients who meet criteria for spinal fusion procedures as defined in Guideline Note 37 only when all of the following criteria are met: 
Lumbar artificial disc replacement
A) Patients must first complete a structured, intensive, multi-disciplinary program for management of pain, if covered by the agency; 
B) Patients must be 60 years or under; 
C) Patients must meet FDA approved indications for use and not have any contraindications. FDA approval is device specific but includes:
* Failure of at least six months of conservative treatment 
* Skeletally mature patient 
* Replacement of a single disc for degenerative disc disease at one level confirmed by patient history and imaging
D) Two level lumbar artificial disc replacement (CPT *22860) is not included on these lines.
GUIDELINE NOTE 101, ARTIFICIAL DISC REPLACEMENT (CONT'D)
Cervical artificial disc replacement
A) Patients must meet FDA approved indications for use and not have any contraindications. FDA approval is device specific but includes: 
* Skeletally mature patient 
* Reconstruction of a single or 2 level disc following single or 2 level discectomy for intractable symptomatic cervical disc disease (radiculopathy or myelopathy) confirmed by patient findings and imaging.
Otherwise, artificial disc replacement is included on Line 517 or Excluded Services Guideline 2.
Artificial disc replacement combined with fusion in a single procedure (hybrid procedure) is not covered.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 102, TRANSCRANIAL MAGNETIC STIMULATION
Line 7
Transcranial magnetic stimulation (CPT *90867-90869) is included on this line only when ALL of the following criteria are met:
A) The patient has a confirmed diagnosis of severe major depressive disorder based on standardized rating scales, AND
B) The patient has treatment resistant depression as evidenced by ongoing symptoms despite treatment with at least 2 psychopharmacologic regimens administered at both an adequate dose and adequate duration that are consistent with the FDA label and with a duration that would elicit a favorable response unless not tolerated or contraindicated; AND
C) The patient does not have psychosis, acute suicidal risk, catatonia, significantly impaired essential function, or other condition for which electroconvulsive therapy (ECT) would be clinically superior to TMS; AND
D) The patient has no contraindications to TMS such as implanted devices in or around the head, increased risk of seizure, etc.; AND
E) The therapy is administered by an FDA approved device in accordance with labeled indications; AND
GUIDELINE NOTE 102, TRANSCRANIAL MAGNETIC STIMULATION (CONT'D)
F) The patient is 18 years of age or older.
Transcranial magnetic stimulation is covered for a maximum of 30 sessions (once a day, up to 5 times per week for 6 weeks) for initial treatment, followed by up to 6 taper treatments. Repeat treatment may be covered if the patient responded to the initial treatment (defined as at least 50 percent reduction in depression score on standardized rating scale) and at least 3 months have elapsed since the initial treatment.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 103, BONE ANCHORED HEARING AIDS
Lines 308,444
Bone anchored hearing aids (BAHA; CPT *69714, 69715; HCPCS L8690-L8694) are included on these lines when the following criteria are met:
A) The patient is aged 5-20 years for initial implanted bone anchored hearing aids or headband mounted BAHA devices; headband mounted BAHA devices may be used for children under age 5; AND
B) The patient has one of the following:
1) Permanent bilateral conductive or mixed hearing loss (for example, congenital malformation of the middle/external ear, microtia, or ossicular disease) unable to be aided by conventional air conducting devices; OR
2) Unilateral conductive hearing loss with ear canal stenosis or ear canal atresia that is unlikely to benefit from surgery; OR
3) Profound unilateral sensorineural hearing loss when the contralateral ear has normal hearing with or without a hearing aid; OR
4) Temporary bilateral conductive hearing loss in patients with cleft palate and middle ear effusions until their palate is repaired and tympanostomy tubes can be placed (for BAHA headband only)
Continuation and maintenance (including repair/replacement) of these devices is included on these lines. This includes patients over the age of 20 who received these devices in childhood or adolescence.
Use of BAHA for treatment of tinnitus is not covered.
GUIDELINE NOTE 104, NEWER INTERVENTIONS FOR OSTEOARTHRITIS OF THE KNEE
Lines 430,462
The following treatments are not included on this line for osteoarthritis of the knee:
* Whole body vibration
* Glucosamine/chondroitin (alone, or in combination)
* Platelet rich plasma
* Viscosupplementation
* Transcutaneous electrical stimulation (TENS)
* Genicular artery embolization
CPT *20610 and 20611 are included on these lines only for interventions other than viscosupplementation for osteoarthritis of the knee.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 105, MEDIASTINITIS
Lines 283,637
ICD-10-CM J98.51 (Mediastinitis) is included on Line 283 for acute mediastinitis and on Line 637 for chronic or fibrosing mediastinitis.
GUIDELINE NOTE 106, PREVENTIVE SERVICES
Lines 3,604
Included on Line 3 are the following preventive services:
A) US Preventive Services Task Force (USPSTF) "A" and "B" Recommendations in effect and issued prior to January 1, 2025.
1)  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations/ 
2) USPSTF "D" recommendations are not included on this line or any other line of the Prioritized List.
B) American Academy of Pediatrics (AAP) Bright Futures Guidelines:
1) http://brightfutures.aap.org. Periodicity schedule available at https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf 
a) Bright Futures is the periodicity schedule for screening for EPSDT for the Oregon Health Plan.
GUIDELINE NOTE 106, PREVENTIVE SERVICES (CONT'D)
2) Screening for lead levels is defined as blood lead level testing and is indicated for Medicaid populations at 12 and 24 months.  In addition, blood lead level screening of any child between ages 24 and 72 months with no record of a previous blood lead screening test is indicated.
C) Health Resources and Services Administration (HRSA) Women's Preventive Services-Required Health Plan Coverage Guidelines (revised October 2025). Available at https://www.hrsa.gov/womens-guidelines as of October 27, 2025.  
D) Immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP): https://www.cdc.gov/vaccines/hcp/imz-schedules/?CDC_AAref_Val=https://www.cdc.gov/vaccines/schedules/hcp/index.html  or approved for the Oregon Immunization Program: https://www.oregon.gov/oha/ph/preventionwellness/vaccinesimmunization/immunizationproviderresources/pages/payor.aspx 
1) COVID-19 vaccines are intended to be included on this line even if the specific administration code(s) do not yet appear on the line when the vaccine has both 1) FDA approval or FDA emergency use authorization (EUA) and 2) ACIP recommendation.
2) Other ACIP recommended vaccines not on the routine vaccine schedule are included on Line 3 when administered according to recommendations specified in the Morbidity and Mortality Weekly Review (MMWR) as required by federal law: https://www.cdc.gov/acip-recs/hcp/vaccine-specific/?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/acip-recs/index.html (retrieved 10/27/25).
Colorectal cancer screening is included on Line 3 for average-risk adults aged 45 to 75, using one of the following screening programs:
A) Colonoscopy every 10 years
B) Flexible sigmoidoscopy every 5 years
C) Fecal immunochemical test (FIT) every year (CPT *82274)
D) Guaiac-based fecal occult blood test (gFOBT) every year
Screening CT colonography (CPT *74263) is only covered for patients who are unable to complete a screening colonoscopy due to colon structural problems (for example, colonic obstruction, stricture, or compression or tortuous or redundant colon).
GUIDELINE NOTE 106, PREVENTIVE SERVICES (CONT'D)
FIT-DNA (CPT *81528) and blood-based colorectal cancer screening tests (HCPCS G0327) are included on Excluded Services Guideline 1.
Colorectal cancer screening for average-risk adults aged 76 to 85 is covered after informed decision making between patients and clinicians which includes consideration of the patient's overall health, prior screening history, and preferences. 
Supervised evidence-based exercise programs for fall prevention for persons aged 65 or older OR younger patients who are at increased risk of falls are included on Line 3 using CPT *98961 or 98962 or HCPCS S9451. HCPCS S9451 is only included on Line 3 for the provision of supervised exercise therapy for fall prevention. Programs should be culturally tailored/culturally appropriate when feasible.
Note: CPT *96110 (Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument) can be billed in addition to other CPT codes, such as evaluation and management (E&M) codes or preventive visit codes. 
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 107, HYPERBARIC OXYGEN 
Line 329
A course of hyperbaric oxygen treatment is included on this line subject to the following limitations:
* Codes appearing on this line from ICD-10-CM E08-E13 are included only when they are diabetic wound ulcers of the lower extremities which are Wagner grade 3 or higher (that is, involving bone or gangrenous) and show no measurable signs of healing after 30 days of adequate standard wound therapies including arterial assessment. Courses of treatment for wounds or ulcers are limited to 30 days after the initial treatment; additional 30-day treatment courses are only covered for patients with incomplete wound/infection resolution AND measurable signs of healing
GUIDELINE NOTE 107, HYPERBARIC OXYGEN (CONT'D)
* ICD-10-CM M27.2 is included on this line for osteoradionecrosis of the jaw only 
* ICD-10-CM O08.0 and M60.0 are included on this line only if the infection is a necrotizing soft-tissue infection 
* ICD-10-CM S07, S17, S38, S47.1, S47.2, S47.9, S57, S67, S77, S87, S97, T79.A are included on this line only for posttraumatic crush injury of Gustilo type III B and C  
* ICD-10-CM T66.XXXA-T66.XXXD and L59.8 are included on this line only for osteoradionecrosis and soft tissue radiation injury 
* ICD-10-CM T86.82, T82.898, T82.9, T83.89, T83.9, T84.89, T84.9, T85.89, T85.9 are included on this line only for compromised myocutaneous flaps
GUIDELINE NOTE 108, CONTINUOUS GLUCOSE MONITORING
Lines 1,8,27,60,147
Real-time (personal) continuous glucose monitoring (CGM) is included on Line 8 for:
A) Adults with type 1 diabetes mellitus not on insulin pump management:
1) Who have received or will receive diabetes education specific to the use of CGM AND
2) Who have baseline HbA1c levels greater than or equal to 8.0%, frequent or severe hypoglycemia, or impaired awareness of hypoglycemia (including presence of these conditions prior to initiation of CGM).
B) Adults with type 1 diabetes on insulin pump management (including the CGM-enabled insulin pump) who have received or will receive diabetes education specific to the use of CGM.
C) Women with type 1 diabetes who are pregnant or who plan to become pregnant within six months without regard to HbA1c levels.
D) Children and adolescents under age 21 with type 1 diabetes who have received or will receive diabetes education specific to the use of CGM.
Real-time (personal) continuous glucose monitoring is included on Line 147 for children or adults with glycogen storage disease type 1a (ICD-10-CM E74.00).
Therapeutic continuous glucose monitors (HCPCS A4239 and E2103) are included on Lines 1 and 27 when ALL of the following criteria (A, B, C and D) are met:
GUIDELINE NOTE 108, CONTINUOUS GLUCOSE MONITORING (CONT'D)
A) The patient has one of the following conditions:
1) Type 2 diabetes; OR
2) Diabetes due to underlying conditions and drug or chemical induced diabetes; OR
3) Gestational diabetes; AND
B) The patient uses short (including fast or rapid)- or intermediate-acting insulin injections; AND
C) The patient has received or will receive diabetes education specific to the use of CGM, AND
D) The patient has one of the following at the time of CGM therapy initiation:
1) Baseline HbA1c levels greater than or equal to 8.0%, OR
2) Frequent or severe hypoglycemia, OR 
3) Impaired awareness of hypoglycemia (including presence of these conditions prior to initiation of CGM), OR
4) Diabetes-related complications (for instance, peripheral neuropathy, end-organ damage)
Requirements for continued CGM coverage:
A) Every 6 months following the initial prescription for CGM, the prescriber must conduct an in-person or telehealth visit with the member to document adherence to their CGM regimen to ensure that CGM is used for diabetes treatment planning. Continued coverage of CGM requires documentation of use of the device for at least 50% of the time since the last visit.
B) Two trials per year of CGM are allowed to meet adherence for continuation of coverage.
Note: Point of care HbA1c testing is acceptable for determining HbA1c levels.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports-Blog.aspx?View={DE654D2C-76D6-4607-B754-C7862C05B54F}&SelectedID=5
GUIDELINE NOTE 109, VERTEBROPLASTY, KYPHOPLASTY, AND SACROPLASTY
Line 474
Vertebroplasty and kyphoplasty are not included on this line (or any other line) for the treatment of routine osteoporotic compression fractures.
GUIDELINE NOTE 109, VERTEBROPLASTY, KYPHOPLASTY, AND SACROPLASTY (CONT'D)
Vertebroplasty and kyphoplasty are only included on this line for the treatment of vertebral osteoporotic compression fractures when they are considered non-routine and meet all of the following conditions:
A) The patient is hospitalized under inpatient status due to pain that is primarily related to a well-documented acute fracture, and 
B) The severity of the pain prevents unassisted ambulation, and
C) The pain is not adequately controlled with oral or transcutaneous medication, and
D) The patient must have failed an appropriate 4-to-6-week trial of conservative management.
Sacroplasty is not included on these or any lines of the Prioritized List for coverage consideration.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 110, CHRONIC PELVIC INFLAMMATORY CONDITIONS
Lines 51,519
Chronic pelvic inflammatory conditions (ICD-10-CM N70.91-N70.93, N71.9, N73.2, N73.4, N73.5, N73.8, N73.9, N74) are included only on Line 519; acute conditions are included on Line 51.
GUIDELINE NOTE 111, INTRA-AORTIC BALLOON PUMPS
Line 69
Intra-aortic balloon pumps (CPT *33967-33974) are included on this line only for use in cardiogenic shock.
GUIDELINE NOTE 112, LUNG VOLUME REDUCTION SURGERY
Line 281
Lung volume reduction surgery (LVRS, CPT *32491, 32672) is included on Line 281 only for treatment of patients with radiological evidence of severe bilateral upper lobe predominant emphysema (ICD-10-CM J43.9) and all of the following:
A) BMI 31.1 kg/m2 or less (men) or 32.3 kg/m2 or less (women)
GUIDELINE NOTE 112, LUNG VOLUME REDUCTION SURGERY (CONT'D)
B) Stable with 20 mg or less prednisone (or equivalent) dose a day
C) Pulmonary function testing showing
1) Forced expiratory volume in one second (FEV 1) 45% or less predicted and, if age 70 or older, FEV 1 at least 15% predicted value
2) Total lung capacity (TLC) at least 100% predicted post-bronchodilator
3) Residual volume (RV) at least 150% predicted post-bronchodilator
D) PCO2, less than or equal to 60 mm Hg (PCO 2, less than or equal to 55 mm Hg if 1-mile above sea level)
E) PO2, at least 45 mm Hg on room air (PO 2, at least 30 mm Hg if 1-mile above sea level)
F) Post-rehabilitation 6-min walk of at least 140 m
G) Non-smoking for 4 months prior to initial surgical evaluation and throughout the pre-surgical process.
1) This must be demonstrated by a plasma cotinine level less than or equal to 13.7 ng/mL (if not using nicotine replacement products), or 
2) an arterial carboxyhemoglobin less than or equal to 2.5% (if using nicotine replacement) prior to surgical authorization.
The procedure must be performed at an approved facility (1) certified by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) under the LVRS Disease Specific Care Certification Program or (2) approved as Medicare lung or heart-lung transplantation hospitals. The patient must have approval for surgery by pulmonary physician, thoracic surgeon, and anesthesiologist post-rehabilitation. The patient must have approval for surgery by cardiologist if any of the following are present: unstable angina; left-ventricular ejection fraction (LVEF) cannot be estimated from the echocardiogram; LVEF <45%; dobutamine-radionuclide cardiac scan indicates coronary artery disease or ventricular dysfunction; arrhythmia (>5 premature ventricular contractions per minute; cardiac rhythm other than sinus; premature ventricular contractions on EKG at rest).
GUIDELINE NOTE 114, FEMOROACETABULAR IMPINGEMENT SYNDROME
Line 353
ICD-10-CM M25.85 (Other specified joint disorders, hip), M24.15 (Other articular cartilage disorders, hip) and M76.2 (Iliac crest spur) pair with CPT codes 29914-29916 (Arthroscopy, hip, surgical) and are included on Line 353 only for the diagnosis and treatment of femoroacetabular impingement syndrome.
GUIDELINE NOTE 114, FEMOROACETABULAR IMPINGEMENT SYNDROME (CONT'D)
Surgery for femoroacetabular impingement syndrome is included on this line only for patients who meet all of the following criteria:
A) Adult patients, or adolescent patients who are skeletally mature with documented closure of growth plates; and
B) Other sources of pain have been ruled out (e.g., lumbar spine pathology, SI joint dysfunction, sports hernia); and
C) Pain unresponsive to physical therapy and other non-surgical management and conservative treatments (e.g., restricted activity, cortisone injections, nonsteroidal anti-inflammatory drugs) of at least three months duration, or conservative therapy is contraindicated; and
D) Moderate-to-severe persistent hip or groin pain that significantly limits activity and is worsened by flexion activities (e.g., squatting or prolonged sitting); and
E) Positive impingement sign (i.e., sudden pain on 90-degree hip flexion with adduction and internal rotation or extension and external rotation); and
F) Radiographic confirmation of FAI (e.g., pistol-grip deformity, alpha angle greater than 50 degrees, coxa profunda, and/or acetabular retroversion); and
G) Do not have advanced osteoarthritis (i.e., Tönnis grade 2 or 3) and/or severe cartilage damage (i.e., Outerbridge grade III or IV).
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 115, EXTRACORPOREAL PHOTOPHERESIS
Lines 158,310
Extracorporeal photopheresis (CPT *36522) is included on Line 158 for treatment of chronic T-cell lymphoma (ICD-10-CM C84.0 and C84.1) which is:
A) stage III or IVA 
B) erythrodermic 
C) not responsive to other therapy
Extracorporeal photopheresis (CPT *36522) is included on Line 310 for treatment of chronic graft-versus-host disease (ICD-10-CM T86.0) which
A) is steroid refractory, steroid dependent or the patient is unable to tolerate corticosteroid therapy
B) primarily affects skin or mucosal membranes (mouth and /or eye disease)
GUIDELINE NOTE 116, ANAL IRRIGATION SYSTEMS
Line 71
Anal irrigation systems (HCPCS A4459, A4453) are included on this line as part of a bowel management program when all of the following criteria are met:
A) The patient has neurogenic bowel dysfunction; and
B) The patient suffers from fecal incontinence, chronic constipation, and/or time-consuming bowel management procedures that significantly impact the individual's quality of life (i.e., inability to participate fully in school or work); and
C) Initial management involving diet, bowel habit, laxatives, or constipating medications has not benefited the patient; and
D) For reauthorization requests only, there is documentation in the provider notes that:
1) The member is consistently using the system as directed by their provider; and
2) The system has shown to be effective in managing fecal incontinence and/or chronic constipation
E) There are no contraindications to an anal irrigation system, such as anal or colorectal stenosis, colorectal cancer, radiotherapy to the pelvis, recent abdomino-perineal surgery, active inflammatory bowel disease, diverticulitis or ischemic colitis.
GUIDELINE NOTE 117, REMOVAL OF TORI AND EXCISION OF HYPERPLASTIC TISSUE
Line 452
D7472 and D7473, and D7970 are included on this line only when used in conjunction with making a prosthesis.
GUIDELINE NOTE 118, SEPTOPLASTY 
Lines 42,119,201,244,285,309,464,495,512,562
Septoplasty is included on Line 309 for gender affirming treatment.
Septoplasty is included on Lines 42, 119, 201, 244, 285, 464, 495, 512 and 562 when
A) The septoplasty is done to address symptomatic septal deviation or deformity which
1) Fails to respond to a minimum 6-week trial of conservative management (e.g. nasal corticosteroids, decongestants, antibiotics); AND
2) Results in persistent or recurrent epistaxis, OR documented recurrent sinusitis felt to be due to a deviated septum and the patient meets criteria for sinus surgery in Guideline Note 35, SINUS SURGERY; OR
B) Septoplasty is performed in association with cleft lip or cleft palate repair or repair of other congenital craniofacial anomalies; OR
GUIDELINE NOTE 118, SEPTOPLASTY (CONT'D)
C) Septoplasty is performed as part of a surgery for a neoplasm or facial trauma involving the nose.
Septoplasty for other nasal obstruction not meeting the criteria above is included only on Line 562.
Septoplasty is not included on these lines for treatment of obstructive sleep apnea and is not included on Line 201 SLEEP APNEA, NARCOLEPSY, INSOMNIA, HYPERSOMNIA, AND REM BEHAVIORAL DISORDER.
GUIDELINE NOTE 119, CAROTID ENDARTERECTOMY
Line 413
Carotid endarterectomy is included on Line 413 for patients in the following groups:
* Symptomatic1 with 70-99% carotid artery stenosis but without near occlusion.
* Symptomatic with 50 - 69% stenosis despite optimal medical management
* Asymptomatic with at least 70% stenosis only for those who do not tolerate (or have contraindications to) best current medical therapy
Carotid endarterectomy is not included on Line 413 for patients in the following groups:
* Patients with near occlusion
* Symptomatic1 patients with less than 50% carotid stenosis
1Symptomatic patients are those who have had a recent transient ischemic attack or ischemic stroke.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 120, TRIGGER THUMB AND TRIGGER FINGER
Lines 373,574
Trigger finger and trigger thumb (ICD-10-CM M65.3 code family) are included on Line 373 only when there is documented interference with function of the hand. Up to 3 steroid injections are covered per digit.
GUIDELINE NOTE 120, TRIGGER THUMB AND TRIGGER FINGER (CONT'D)
Surgery for trigger finger or trigger thumb included on Line 373 only in ONE of the following situations:
A) The triggering persists or recurs after at least one steroid injection or a minimum of 3 weeks of splinting has been tried; OR
B) The patient has diabetes; OR
C) The finger or thumb is permanently locked in the palm; OR
D) The patient is a child up to age 21 who has a trigger thumb or trigger finger
Otherwise, trigger finger and trigger thumb are included on Line 574.
GUIDELINE NOTE 121, CONCUSSION AND POST-CONCUSSION SYNDROME
Lines 91,200,594
ICD-10-CM S06.0X0, S06.2X0 and S06.300 are included on Line 91 only for concussions with symptoms that persist for more than 7 days but less than 3 months; otherwise, these diagnoses are included on Line 594. When concussion symptoms last for more than 3 months, the diagnosis of post-concussive syndrome (ICD-10-CM F07.81) should be used, which is included on Line 200.
GUIDELINE NOTE 122, ORAL HEALTH RISK ASSESSMENT IN MEDICAL SETTINGS
Line 3
D0191 is limited to children under age 6 and requires an additional specific oral health risk assessment using a standardized tool, such as AAP Bright Futures, and should be performed by a provider who has successfully completed an approved training program (such as First Tooth or Smiles for Life).
GUIDELINE NOTE 123, DENTAL IMPLANT REMOVAL 
Lines 341,601
Removal of dental implants (D6100, D6105) is included on Line 341 only when there is advanced peri-implantitis with bone loss and mobility, abscess or implant fracture. Otherwise, this procedure is included on Line 601.
GUIDELINE NOTE 124, ALCOHOL SEPTAL ABLATION
Line 98
Alcohol septal ablation (CPT *93583) is included on Line 98 only for adult patients with hypertrophic cardiomyopathy when all of the following conditions are met:
A) Severe heart failure symptoms (New York Heart Association [NYHA] class III or IV)
B) Severe symptoms refractory to optimal medical management 
C) LVOT obstruction is present
D) Surgery is contraindicated or has unacceptable risk due to serious comorbidities or advanced age.
E) No concomitant disease is present that independently warrants surgical correction in whom surgical myectomy can be performed as part of the operation.
F) The ablation is performed at an experienced center.
GUIDELINE NOTE 125, CAROTID ARTERY STENTING
Lines 314,413
Carotid artery stenting (CPT *37215-37217) is included on Lines 314 and 413 only for patients who have not had a disabling stroke (modified Rankin scale 3 or greater) AND
A) who are at high risk for complications during carotid endarterectomy (CEA) due to the following significant comorbidities and/or anatomic risk factors and who also have symptomatic (recent transient ischemic attack or ischemic stroke) carotid artery stenosis >50% and have clinical documentation of one or more of the following:
Comorbidities:
* cardiovascular comorbidities (for example, clinically significant cardiac disease, recent myocardial infarction, congestive heart failure, ejection fraction < 30%, abnormal stress test, need for coronary artery bypass graft)
* severe pulmonary disease
* perioperative stroke/death rates >3% according to a validated risk calculator
Anatomic risk factors:
* recurrent stenosis in setting of previous CEA
* prior radiation treatment to neck
* previous radical neck dissection
* permanent contralateral cranial nerve injury
GUIDELINE NOTE 125, CAROTID ARTERY STENTING (CONT'D)
* contralateral carotid occlusion
* tandem high-grade stenosis on the same side
* high cervical carotid stenosis above C2 vertebral body
B) Carotid artery stenting is not included on these lines for asymptomatic patients.
GUIDELINE NOTE 126, APPLIED BEHAVIOR ANALYSIS INTERVENTIONS FOR SELF-INJURIOUS BEHAVIOR
Line 436
Targeted ABA-based interventions towards self-injurious problem behaviors are included on this line when meeting criteria as defined in Guideline Note 75 APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER.
GUIDELINE NOTE 127, GENDER AFFIRMING TREATMENT
Line 309
Gender affirming treatments are included on this line according to the provisions of ORS 414.769, when provided according to Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, published by the World Professional Association of Transgender Health (WPATH), whether or not the code for the service appears on the line. These services are included for gender affirming treatment or for any condition represented on this line. To simplify administration, the line includes a variety of procedures that may be considered medically necessary and prescribed in accordance with the WPATH 8.0 standards of care.
Gender affirming treatments billed using CPT or HCPCS codes not on this line must also be covered in accordance with the provisions of the statute.
In addition, the statute prohibits denial or limitation of services determined to be medically necessary by the provider who prescribed the treatment, prohibits denying or limiting services considered by plans to be 'cosmetic' and requires that any denial or limit be reviewed and upheld by a provider with experience prescribing or delivering gender affirming treatment.
GUIDELINE NOTE 128, FOREIGN BODIES IN THE GI TRACT
Line 41
Endoscopy procedures only pair with ICD-10-CM T18.2XXD, T18.3XXD, T18.4XXD, T18.5XXD, T18.8XXD, T18.9XXD) when hazardous objects are involved that are likely to cause perforation (e.g. sharp objects >2 inches, neodymium magnets, button batteries) or obstruction.
GUIDELINE NOTE 129, FECAL INCONTINENCE
Lines 71,516
ICD-10-CM R15.9 (Full incontinence of feces) is included on Line 71 only for supportive equipment (e.g. diapers, gloves). Surgical treatment for fecal incontinence is included on Line 516 DISORDERS OF FUNCTION OF STOMACH AND OTHER FUNCTIONAL DIGESTIVE DISORDERS
Sacral nerve stimulation is included on Line 516 only for fecal incontinence and only when all of the following criteria are met:
A) Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment); AND
B) A successful percutaneous test stimulation, defined as at least 50% sustained (more than one week) improvement in symptoms; AND
C) Condition is not related to anorectal malformation and/or chronic inflammatory bowel disease; AND
D) Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.
GUIDELINE NOTE 130, BLEPHAROPLASTY
Lines 309,470
Blepharoplasty is included on Line 470 when 1) a minimum of 30 degrees of visual field loss exists with upper lid skin/margin in repose, 2) upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket, OR 3) essential blepharospasm or hemifacial spasm is present. 
GUIDELINE NOTE 131, HYPOTONY
Lines 283,634
ICD-10-CM H44.40-H44.439 (hypotony of the eye) are only included on Line 283 when resulting from a complication of a procedure. Non-procedure related cases are included on Line 634.
GUIDELINE NOTE 132, ACNE CONGLOBATA AND ACNE FULMINANS
Lines 370,451
Acne conglobata is only included on Line 370 if it involves recurrent abscesses or communicating sinuses. ICD-10 L70.0 is included on Line 370 only for acne fulminans.
GUIDELINE NOTE 133, ACUTE PERIPHERAL MOTOR AND DIGITAL NERVE INJURY
Lines 206,498,524
Repair of acute (<6 months) peripheral nerve injuries are included on Line 206. Non-surgical medical care of these injuries are included on Line 498. Surgical repair of chronic nerve injuries are included on Line 524.
GUIDELINE NOTE 134, NEONATAL NASOLACRIMAL DUCT OBSTRUCTION
Lines 390,499
Probing of nasolacrimal duct (CPT *68810-68840) is included on Line 390 only for children 12 months of age and older who have failed conservative management (e.g. topical antibiotics, Crigler massage) and for children younger than 12 months of age with multiple episodes of purulent infections.
GUIDELINE NOTE 135, EHLERS-DANLOS SYNDROME
Line 141
Ehlers-Danlos syndrome (EDS) is included on this line when a patient has a known genetic marker or when they otherwise meet the criteria outlined in the 2017 international expert guideline (Malfait et al., 2017, The 2017 international classification of the Ehlers-Danlos syndromes). Diagnostic testing, including genetic testing and diagnostic echocardiograms, are covered when medically necessary to make a diagnosis.
There is no effective treatment for Ehlers-Danlos syndrome. However, this condition may result in multiple manifestations, including joint sprains, strains and dislocations and 
GUIDELINE NOTE 135, EHLERS-DANLOS SYNDROME (CONT'D)
cardiovascular problems, for which treatments should be covered when medically necessary and appropriate. Patients who meet the 2017 diagnostic criteria for vascular EDS should be monitored with echocardiograms no more than once per year unless symptomatic or having known cardiovascular disease. Because of frequent comorbidities and multiple manifestations of EDS, provider and plans should carefully monitor interactions of prescribed treatments to avoid contraindications and harm. For EDS patients who also have chronic pain, see Statement of Intent 5 Treatment of Chronic Pain.
GUIDELINE NOTE 136, COLLAPSED VERTEBRA
Lines 150,474
Diagnosis codes appearing on this line for collapsed vertebra (in the ICD-10-CM M48.5 series) are included on Line 150 for a fracture that qualified for trauma system entry or a fracture with spinal cord injury.
GUIDELINE NOTE 137, BENIGN BONE AND JOINT TUMORS
Lines 399,545
Treatment of benign conditions of joints are included on Line 399 for those conditions only when there are significant functional problems of the joint due to size, location, or progressiveness of the disease. Treatment of all other benign joint conditions are included on Line 545.
Treatment of benign tumors of bones are included on Line 399 for those neoplasms associated with pathologic fractures, at high risk of fracture, or which cause function problems including impeding joint function due to size, causing nerve compression, have malignant potential or are considered precancerous. Treatment of all other benign bone tumors are included on Line 545
GUIDELINE NOTE 138, OBSTRUCTIVE AND REFLUX UROPATHY 
Line 21
ICD-10-CM N13.9 (Obstructive and reflux uropathy unspecified) appears on this line for pediatric populations only.
GUIDELINE NOTE 139, FRENOTOMY FOR TONGUE TIE IN NEWBORNS AND CANCER TREATMENT 
Lines 18,163,285,341,580
Ankyloglossia (ICD-10-CM Q38.1) is included on Line 18 for pairing with frenotomy (CPT *41010, CDT **D7962) only when it interferes with breastfeeding. Otherwise, Q38.1 and CDT **D7962 are included on Line 580; CPT *41010 is included on Line 163 for treatment of cancer and on Line 580 for tongue tie when not interfering with breastfeeding. CPT *41115 is not included on Line 18; it is included on Line 580 when used for tongue tie treatment and on Lines 163 and 285 when used for cancer treatment. CPT *41520 is only included on Line 163 for treatment of oral cancer. CDT **D7963 is included on the oral surgery line for use in complicated oral surgery and on line Line 163 for use in treatment of oral cancer.
GUIDELINE NOTE 140, BREASTFEEDING SUPPORT AND SUPPLIES
Line 3
Breast pumps and supplies are covered for postpartum women when a pump is necessary to establish or maintain milk production in order to maximize availability of breast milk to the baby.
For cases in which there is a medical indication for breast pumps, the pumps should be supplied whenever possible within 24 hours to allow for continued milk production.
Lactation support services (including education and counseling by trained providers) are covered for pregnant and postpartum women (for six months postpartum).
GUIDELINE NOTE 141, LARYNGEAL STENOSIS OR PARALYSIS; DYSPHONIA
Lines 66,506
Laryngeal and vocal cord paralysis (ICD-10-CM J38.00-J38.02) are included on Line 66 if associated with recurrent aspiration pneumonia (unilateral or bilateral) or airway obstruction (bilateral). Vocal cord paralysis is included on Line 66 for children 18 and under with dysphonia or dysphagia persisting for at least twelve months. Treatment of hoarseness and dysphonia in adults are included only on Line 506. Laryngeal stenosis (ICD-10-CM J38.6) is included on Line 66 only if it causes airway obstruction; otherwise it is included on Line 506.
GUIDELINE NOTE 142, STEREOTACTIC BODY RADIATION THERAPY
Lines 157,158,190,198,214,256,257,260,284,311,312,326,395
Stereotactic body radiation therapy (CPT *32701, 77373, 77435, HCPCS G0563) is included on these lines only when:
A) Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist; AND
B) The patient has one of the following:
1) Very low, low, and intermediate risk prostate cancer, as defined by NCCN based on stage, Gleason score, and PSA level; OR
2) Non-Small Cell Lung Cancer (NSCLC) when:
a) Stage I and Stage II (node negative), and 
b) Tumor is deemed to be unresectable, or patient is deemed too high risk, or the patient declines operative intervention; OR
3) Small Cell Lung Cancer (SCLC) when:
a) Stage I and Stage II (node negative), and
b) Tumor is deemed to be unresectable, or patient is deemed too high risk, or the patient declines operative intervention; OR
4) Oligometastatic disease when each of the following conditions are met: 
a) Five or fewer total metastatic lesions (maximum 3 per organ), and
b) Controlled primary tumor.
GUIDELINE NOTE 143, TREATMENT OF UNILATERAL HEARING LOSS
Lines 308,444
Unilateral hearing loss treatment is Included on these lines only for children aged 20 and younger with the following conditions:
* For mild to moderate sensorineural unilateral hearing loss (defined as 26-70 dB hearing loss at 500, 1000 and 2000 Hz), first line intervention should be a conventional hearing aid, with second line therapy being contralateral routing of signal (CROS) system:
* For severe to profound unilateral sensorineural hearing loss (defined as 71 dB hearing loss or greater at 500, 1000 and 2000 Hz), first line therapy should be a contralateral routing of signal (CROS) system with second line therapy being a bone anchored hearing aid (BAHA). BAHA SoftBand therapy may be first line therapy for children under age 5 or patients with severe ear deformities (e.g. microstia, severe canal atresia). Unilateral cochlear implants may be considered per Guideline Note 31 COCHLEAR IMPLANTATION.
GUIDELINE NOTE 144, RADIOFREQUENCY ABLATION OF BENIGN THYROID NODULES
Line 339
Radiofrequency ablation of benign thyroid nodules is included on this line when the following criteria are met:
* The nodule is confirmed to be benign on fine needle aspiration 
* The patient has compressive symptoms (e.g., changes of voice, dysphagia, dyspnea, pain)
GUIDELINE NOTE 145, TREATMENTS FOR BENIGN PROSTATE ENLARGEMENT WITH LOWER URINARY TRACT SYMPTOMS
Line 324
For men with lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH), surgical procedures are included on this line for patients with one of the following:
   A) 	Renal insufficiency secondary to BPH; OR
   B)	Refractory urinary retention; OR
   C)	Recurrent urinary tract infections due to BPH; OR
   D)	Recurrent bladder stones or gross hematuria due to BPH; OR
E)	Severe symptoms (International Prostate Symptom Score (IPSS) of 20-35) in patients with documented failure of, contraindication to, intolerance to, or individual non-acceptance of at least 3 months of conventional pharmacologic management (for example, alpha-blocker, phosphodiesterase inhibitor, 5-alpha reductase inhibitor).
Prostatic urethral lift procedures (CPT *52441, 52442, HCPCS C9739, C9740) are included on Line 324 when the following criteria are met:
* Age 45 or older
* Estimated prostate volume less than or equal to 80 cc
* IPSS 13 or greater
* No obstructive median lobe of the prostate identified on cystoscopy at the time of the procedure
The following interventions for benign prostate enlargement are not included on Line 324 due to lack of evidence of effectiveness:
* Botulinum toxin
GUIDELINE NOTE 145, TREATMENTS FOR BENIGN PROSTATE ENLARGEMENT WITH LOWER URINARY TRACT SYMPTOMS (CONT'D)
* HIFU (High Intensity Focused Ultrasound)
* TEAP (Transurethral Ethanol Ablation of the Prostate)
* Laser coagulation (for example, VLAP/ILC)
* Prostatic artery embolization
* Transurethral thermal ultrasound ablation
* Temporary device for ischemic remodeling
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 146, ABLATION PROCEDURES FOR ATRIAL FIBRILLATION/ATRIAL FLUTTER
Line 344
AV nodal ablation (CPT *33250, 33251,33261,93650) pairs with atrial fibrillation and atrial flutter (ICD-10-CM I48.0) only for patients with inadequate ventricular rate control resulting in symptoms, left ventricular systolic dysfunction or substantial risk of left ventricular systolic dysfunction, when pharmacological therapy for rate control is ineffective or not tolerated
Other forms of ablation (CPT *93653-93656) are included on this line for atrial fibrillation and atrial flutter as first line therapy.
Transcatheter pulmonary vein isolation (93656-93657) pairs with atrial fibrillation (ICD-10-CM I48.0, I48.1, I48.2, I48.91) only for patients who remain symptomatic from atrial fibrillation despite rate control medications and antiarrhythmic medications.
Surgical ablation (pulmonary vein isolation or Maze procedure) (CPT *33254-33259, 33265, 33266) only pairs with atrial fibrillation and atrial flutter (ICD-10-CM I48.0) at the time of other cardiac surgery for patients who remain symptomatic despite rate control medications.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 147, IVC FILTERS FOR ACTIVE PULMONARY EMBOLISM (PE)/DEEP VEIN THROMBOSIS (DVT)
Lines 1,78,212,278,283
Inferior vena cava (IVC) filter placement (CPT *37191) is included on these lines for patients with active deep vein thrombosis/pulmonary embolism (DVT/PE) for which anticoagulation is contraindicated. IVC filter placement is not included on these lines for patients with DVT who are candidates for anticoagulation. 
Retrieval of removable IVC filters (CPT *37193) is included on these lines when the benefits of removal outweigh the harms.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 148, BIOMARKER TESTS OF CANCER TISSUE
Lines 157,183,190,228,260,269,326
The use of tissue of origin testing (e.g. CPT *81504) is included on Excluded Services Guideline 2.
For early stage breast cancer, the following breast cancer genome profile tests are included on Line 190 when the listed criteria are met.  One test per primary breast cancer is covered when the patient is willing to use the test results in a shared decision-making process regarding adjuvant chemotherapy.  Lymph nodes with micrometastases less than 2 mm in size are considered node negative.
* Oncotype DX Breast Recurrence Score (CPT *81519) for breast tumors that are estrogen receptor positive, HER2 negative, and either lymph node negative, or lymph node positive with 1-3 involved nodes.
* EndoPredict (CPT *81522) and Prosigna (CPT *81520 or PLA 0008M) for breast tumors that are estrogen receptor positive, HER2 negative, and lymph node negative.
* MammaPrint (using CPT *81521, 81523 or HCPCS S3854) for breast tumors that are estrogen receptor or progesterone receptor positive, HER2 negative, lymph node negative, and only in those cases categorized as high clinical risk.
GUIDELINE NOTE 148, BIOMARKER TESTS OF CANCER TISSUE (CONT'D)
For early stage breast cancer that is estrogen receptor positive, HER2 negative, and either lymph node negative or lymph node positive with 1-3 involved nodes, Breast Cancer Index (CPT *81518) is included on Line 190 when the patient is willing to use the test results in a shared decision-making process regarding prolonged adjuvant endocrine therapy.
EndoPredict, Prosigna, and MammaPrint are not included on Line 190 for early stage breast cancer with involved axillary lymph nodes.  Oncotype DX Breast Recurrence Score is not included on Line 190 for breast cancer involving four or more axillary lymph nodes or more extensive metastatic disease. 
Oncotype DX Breast DCIS Score (CPT *81479) is included on Excluded Services Guideline 2.
For melanoma, DecisionDx-Melanoma (CPT *81529) is included on Excluded Services Guideline 2.
For colorectal cancer, Oncotype DX (CPT *81519) is not included on Line 157.
For bladder cancer, Urovysion testing is included on Excluded Services Guideline 2.
For prostate cancer, Oncotype DX Genomic Prostate Score and Prolaris Score Assay (CPT *81541) are included on Excluded Services Guideline 2.
For thyroid cancer, Afirma gene expression classifier (CPT *81546) is included on Excluded Services Guideline 2.
The development of this guideline note was informed by a HERC coverage guidance on Biomarkers Tests of Cancer Tissue for Prognosis and Potential Response to Treatment; the prostate-related portion of that coverage guidance was superseded by a Coverage Guidance on Gene Expression Profiling for Prostate Cancer. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 149, SCLEROTHERAPY OF FLUID COLLECTIONS
Lines 167,223,291,420,422,475,531,543,552,577,587,612
Sclerotherapy for fluid collections (CPT *49185) is included on these lines only for the treatment of cysts, seromas or lymphoceles which are causing bleeding, infection, severe pain, organ torsion, or organ dysfunction.
GUIDELINE NOTE 150, FETAL MRI
Line 1
Fetal MRI (CPT *74712-74713) is included on this line only when all of the following conditions are met:
A) Abnormalities are found on fetal ultrasound performed by an experienced sonologist which cannot be adequately further evaluated by 2D or 3D ultrasound
B) The information obtained by fetal MRI is necessary for decisions about fetal or neonatal therapy, delivery planning, or to advise a family about prognosis 
C) The fetus is 18 weeks gestational age or older
D) The MRI is performed and interpreted at a center with technicians and radiologists who are either trained or highly experienced in fetal MRI and which has appropriate MRI equipment, with a minimum of a 1.5 Tesla magnet.
GUIDELINE NOTE 151, CARDIAC TRANSPLANT GENETIC TESTING FOR TRANSPLANT REJECTION
Lines 239,262
Genetic testing for cardiac transplant rejection (CPT *81595) is included on these lines only for patients at least 6 months post transplant who are without clinical signs of rejection.
Donor-derived cell-free DNA (dd-cfDNA; CPT *81479 or PLA 0118U) is not included on these lines for the management of patients after heart transplant.
GUIDELINE NOTE 152, MICROTIA
Lines 404,585
ICD-10-CM Q17.2 (Microtia) is included on Line 404 for external ear reconstruction when ANY of the following criteria are met:
A) Hearing is expected to improve; OR
GUIDELINE NOTE 152, MICROTIA (CONT'D)
B) Reconstruction is necessary to allow for use of a conventional air conduction hearing aid; OR
C) The external ear deformity is preventing the functional ability to use eyewear for the correction of visual loss; OR
D) The patient is under 21 years of age and reconstruction is determined to be medically appropriate and necessary after individual case review.
Otherwise, this diagnosis is included on Line 585.
GUIDELINE NOTE 153, PLANNED COMMUNITY BIRTH
Lines 1,2
Planned community birth is included on this line for pregnant women who are at low risk for adverse obstetric or birth outcomes. The high-risk conditions outlined below would either preclude coverage of planned community birth, necessitate a consultation, or require transfer of the mother or infant to a hospital setting. When a condition requiring transfer arises during labor, an attempt should be made to transfer the mother and/or her newborn; however, imminent fetal delivery may delay or preclude actual transfer prior to birth.
Coverage of prenatal, intrapartum, and postpartum care is recommended with the performance of appropriate risk assessments (at initiation of care and throughout pregnancy and delivery) and the community birth attendant's adherence to the consultation and transfer criteria as outlined below.
When a high-risk condition develops that requires transfer or planned hospital birth, coverage is recommended when appropriate care is provided until the point the high-risk condition is identified. For women who have a high-risk condition requiring consultation, ongoing coverage of planned community birth care is recommended as long as the consulting provider's recommendations are then appropriately managed by the community birth attendant in a planned community birth setting.
HIGH-RISK CONDITIONS
Conditions designated as "transfer" indicate high-risk conditions that require planned 
GUIDELINE NOTE 153, PLANNED COMMUNITY BIRTH (CONT'D)
hospital birth (when present on intake) or transfer of the mother or infant to hospital-based care (when condition develops).
Conditions designated as "consultation" indicate potentially risky conditions that require consultation. Consultations may be with 1) a provider (MD/DO or CNM) who has active admitting privileges to manage pregnancy in a hospital and/or 2) appropriate specialty consultation (e.g., maternal-fetal medicine, hepatologist, hematologist, psychiatrist).
This list of high-risk conditions is not exhaustive, and other, physical health, behavioral health, obstetric, or fetal high-risk conditions may arise that require consultation and/or transfer to hospital-based care. Having multiple risk conditions requiring consultation may increase the risk sufficiently to indicate the need for transfer of care.
MEDICAL HISTORY OR OBSTETRIC HISTORY
Type of condition
Consultation/transfer criteria
Cancer
* Active gynecologic cancer (transfer required)
Cardiovascular Disease
* Cardiovascular disease causing functional impairment (consultation required)
Connective Tissue Disorders
* Systemic lupus erythematous (consultation required)
* Scleroderma (consultation required)
* Rheumatoid arthritis (consultation required)
* Any collagen-vascular disease (consultation required)
Delivery History
* Prior cesarean section (transfer required)
Diabetes Mellitus
* Type 1 diabetes (transfer required)
* Type 2 diabetes (transfer required)
Endocrine Conditions 
* Significant endocrine conditions other than diabetes (e.g. hyperthyroidism) (consultation required)
Fetal Demise or Stillbirth
* Prior stillbirth/neonatal death (consultation required)
Hematologic Disorders
* Maternal bleeding disorder (transfer required)
* Hemoglobinopathies (consultation required)
* History of thrombosis or thromboembolism (consultation required)
* History of postpartum hemorrhage requiring transfusion or other advanced treatment (e.g. Bakri balloon) (consultation required)
Hypertensive Disorders
* Eclampsia (transfer required)
* Pre-eclampsia requiring preterm birth (transfer required)
* HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) (transfer required)
* Pre-existing or chronic hypertension (transfer required)
Infectious Diseases
* HIV positive (transfer required)
Isoimmunization
* Blood group incompatibility and/or Rh sensitization in a prior pregnancy (consultation required)
Neonatal Encephalopathy in prior pregnancy
* Neonatal encephalopathy in prior pregnancy (consultation required)
Neurological disorders
* Neurological disorders or active seizure disorders that would impact maternal or neonatal health (e.g. epilepsy, myasthenia gravis, previous cerebrovascular accident) (transfer required)
Placental Conditions
* History of retained placenta requiring surgical removal (transfer required)
Psychiatric Conditions
* History of postpartum mood disorder with high risk to the infant (e.g. psychosis) (consultation required)
* Schizophrenia, other psychotic disorders, bipolar I disorder or schizotypal disorders (consultation required)
Pulmonary Disease
* Chronic pulmonary disease (e.g. cystic fibrosis) (consultation required)
Renal Disease
* Renal disease requiring supervision by a renal specialist (transfer required)
* Renal failure (transfer required)
(Preeclampsia and related conditions are listed separately)
Shoulder Dystocia
* History of, with or without fetal clavicular fracture (consultation required)
Uterine Conditions
* Prior myomectomy (consultation required)
Uterine Conditions
* Prior hysterotomy (transfer required)
CONDITIONS OF CURRENT PREGNANCY
Type of condition
Consultation/transfer criteria
Abnormal Bleeding in pregnancy
Antepartum hemorrhage, recurrent (transfer required)
Hemorrhage (hypovolemia, shock, need for transfusion, vital sign instability) (transfer required)
Amniotic Membrane Rupture
Before 37 weeks 0 days (transfer required)

Pre-labor rupture > 24 hours (consultation required)
Congenital or Hereditary Anomaly of the fetus
Evidence of congenital anomalies requiring immediate assessment and/or management by a neonatal specialist (consultation required)
Diabetes, Gestational 
Requiring medication or uncontrolled (transfer required)
Fetal Growth
Uteroplacental insufficiency (transfer required)
IUGR (defined as fetal weight less than fifth percentile using ethnically-appropriate growth tables, or concerning reduced growth velocity on ultrasound) (transfer required)
Fetal Growth
Inappropriate uterine growth (size-date discrepancy). (An ultrasound read by a qualified physician constitutes a consultation) (consultation required)
Fetal presentation
Breech or noncephalic presentation (transfer required)
Gestational age  
< 37 weeks 0 days (transfer required)
42 weeks 0 days or later (unless already in active labor at 41 weeks 6 days) (transfer required)
Gestational age  
Expected date of delivery (EDD) uncertain (consultation required)
Hematologic conditions
Anemia with hemoglobin < 8.5 g/dL (current pregnancy) (transfer required)
Suspected or diagnosed thrombosis or thromboembolism (transfer required)
Thrombocytopenia (platelets < 100,000) (transfer required)

Hemoglobin < 10 g/dL, unresponsive to treatment (consultation required)
Hepatic disorders
Disorders including uncontrolled intrahepatic cholestasis of pregnancy and/or abnormal liver function tests (consultation required)
Hyperemesis gravidarum
Refractory (consultation required)
Hypertensive disorders
Elevated blood pressure on two occasions 30 minutes apart (e.g. gestational hypertension or pregnancy-induced hypertension) (transfer required)
* Systolic 140 or greater or diastolic 90 or greater
Elevated blood pressure on one occasion (transfer required)
* Systolic 160 or greater or diastolic 110 or greater, or
* Systolic 140 or greater or diastolic 90 or greater, with severe pre-eclampsia features 
Pre-eclampsia (transfer required)
Eclampsia (transfer required)
HELLP syndrome (transfer required)
Infectious conditions
HIV, Hepatitis B or syphilis positive (transfer required)
Chorioamnionitis (transfer required)
Maternal temperature 38.0 C or higher in labor/postpartum
Genital herpes at time of labor (transfer required)
Maternal infection postpartum (e.g., endometritis, sepsis, wound) requiring hospital treatment (transfer required)
Rubella (transfer required)
Tuberculosis (other than latent) (transfer required)
Toxoplasmosis (transfer required)
Varicella (active at labor) (transfer required)
Isoimmunization
Blood group incompatibility and/or Rh sensitization in current pregnancy (transfer required)
Labor management
Induction (transfer required)
Failure to progress/failure of head to engage in active labor (transfer required)
Lack of adequate progress in 2nd stage with cephalic presentation (transfer required)
Miscarriage/non-viable pregnancy
Molar (transfer required)
Multiple gestations
Multiple gestations (transfer required)
Oligohydramnios or polyhydramnios
Oligohydramnios (transfer required)
Polyhydramnios (transfer required)
Perineal laceration or obstetric anal sphincter injury
3rd degree requiring hospital repair or beyond expertise of attendant (transfer required)
4th degree (transfer required)
Enlarging hematoma (transfer required)
Placental conditions
Low lying placenta within 2 cm or less of cervical os at 38 weeks 0 days or later (transfer required)
Placenta previa (transfer required)
Vasa previa (transfer required)
Abruption (transfer required)
Retained placenta > 60 minutes (transfer required)
Psychiatric conditions
Maternal mental illness requiring psychological or psychiatric intervention (consultation required)
Patient currently taking psychotropic medications (consultation required)
Renal 
Acute pyelonephritis (consultation required)
Substance Use
Drug or alcohol misuse with high risk for adverse effects to fetal or maternal health (transfer required)
Umbilical cord
Prolapse (transfer required)
Uterine condition
Anatomic anomaly (e.g. bicornuate, large fibroid impacting delivery) (consultation required)
Uterine prolapse (consultation required)
Uterine condition
Uterine rupture, inversion (transfer required)
The development of this guideline note was informed by a HERC Coverage Guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 154, EAR DRUM REPAIR
Lines 308,444,472
Repair of open wounds or perforations of the ear drum (ICD-10-CM H72 and S09.2) are only included on Lines 308 and 444 when there is documented conductive hearing loss greater than or equal to 25dB persistent for more than three months. Otherwise, such repairs are included on Line 472 CHRONIC OTITIS MEDIA; OPEN WOUND OF EAR DRUM.
GUIDELINE NOTE 155, ELECTRIC TUMOR TREATMENT FIELDS FOR GLIOBLASTOMA
Line 292
Electric tumor treatment fields (HCPCS E0766) are included on this line only when:
A) Used for the initial treatment of either a
1) supratentorial glioblastoma OR
2) supratentorial IDH-mutant WHO grade 4 astrocytoma; AND
B) Used in combination with temozolomide and standard radiation therapy; AND
C) The patient is age 22 or older.
Electric tumor treatment fields are not included on this line for recurrent glioblastoma or astrocytoma or any other indication.
GUIDELINE NOTE 156, ENCOUNTER FOR TESTING AND DESENSITIZATION TO ALLERGENS
Lines 9,102,123,221,310,520,521,539,548,554
ICD-10-CM Z01.82 (Encounter for allergy testing) is only included on these lines when:
A) Used to diagnose an allergy that affects a diagnosis appearing on a line above the current funding line (e.g. asthma, severe eczema); AND
B) Symptoms are not adequately controlled by empiric conservative therapy; AND
C) Testing must correlate specifically to the member's history, risk of exposure and physical findings; AND
D) Test technique and/or allergens tested must have proven efficacy demonstrated through scientifically valid medical studies published in the peer-reviewed literature.
ICD-10-CM Z51.6 (Encounter for desensitization to allergens) is only included on these lines when:
A) Used to treat a diagnosis appearing on Lines 9, 102, 123, 221 and 310, AND
B) The patient has a properly performed skin test and/or serologic evidence of IgE-mediated antibody to a potent extract of the allergen, AND
C) Hypersensitivity to allergen cannot be adequately managed by appropriate medication therapy or allergen avoidance.
GUIDELINE NOTE 157, WIGS
Lines 422,571
Wigs (HCPCS A9282) are covered only for hair loss due to chemotherapy or radiation therapy.
ICD-10-CM codes L58.0 (Acute radiodermatitis), L64.0 (Drug-induced androgenic alopecia) and L65.8 (Other specified nonscarring hair loss) are only included on Line 422 for pairing with HCPC A9282 (Wig). Otherwise, these ICD-10-CM codes are included on Line 571.
GUIDELINE NOTE 158, HALLUX RIGIDUS
Lines 353,529
Surgical treatment of hallux rigidus is included on Line 353 only for:
* Stage 3 and 4 disease when paired with arthroplasty (CPT *28750), the Keller procedure (CPT *28292), or cheilectomy with implant (CPT *28291)
* Stage 2 disease when paired with cheilectomy (CPT *28289) and there is documentation that conservative therapy (e.g., injection, physical therapy, non-custom-made orthotics) has been tried and failed to adequately control symptoms.
Otherwise, surgical treatment of this diagnosis is included on Line 529.
GUIDELINE NOTE 159, CARDIAC RESYNCHRONIZATION THERAPY
Lines 97,98,110,279,283
Cardiac resynchronization therapy (CRT) is only covered for patients with NYHA Class II-III and ambulatory IV heart failure with an ejection fraction less than or equal to 35% as well as one of the following:
A) Left bundle branch block (LBBB) and a QRS complex over 120 msec; OR
B) QRS complex greater than or equal to 150ms
CRT-pacemaker is covered when CRT is covered.
GUIDELINE NOTE 160, CONGENITAL MUSCULAR TORTICOLLIS
Line 400
Congenital muscular torticollis (ICD-10-CM Q68.0 Congenital deformity of sternocleidomastoid muscle) is paired with physical therapy on this line only in the following circumstances:
A) The patient is a child aged 2 years or younger 
B) For patients with deficits of passive rotation of the neck of < 10 degrees, one therapy visit is included for instructing caregivers on home treatment. 
C) For patients with deficits of passive rotation of the neck of > 10 degree or with deficits of passive rotation of the neck of < 10 degrees who have had no improvement after 4 weeks of home treatment, physical therapy is included on this line according to Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES.
GUIDELINE NOTE 161, SACROILIAC JOINT INJECTIONS AND SACROILIAC JOINT FUSION
Lines 396,517
Sacroiliac joint (SIJ) injection (CPT *20610, 20611 and 27096, and HCPCS G0260) is included on these lines for diagnostic sacroiliac injections with anesthetic only, but not for therapeutic injections or corticosteroid injections. Injections are only covered for patients for whom SIJ fusion surgery is being considered.
SIJ fusion (CPT *27279) is included on Line 396 for patients who have all of the following:
A) Baseline score of at least 30% on the Oswestry Disability Index (ODI) 
GUIDELINE NOTE 161, SACROILIAC JOINT INJECTIONS AND SACROILIAC JOINT FUSION (CONT'D)
B) Undergone and failed a minimum six months of intensive non-operative treatment that must include non-opioid medication optimization and active therapy.  Active therapy is defined as activity modification, chiropractic/osteopathic manipulative therapy, bracing, and/or active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program. Failure of conservative therapy is defined as less than a 50% improvement on the ODI.
C) Typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIJ, and consistent with SIJ pain.
D) Thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus (Fortin's point, i.e. at the insertion of the long dorsal ligament inferior to the posterior superior iliac spine or PSIS) in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and that other obvious sources for their pain do not exist.
E) Positive response to at least three of six provocative tests (e.g. thigh thrust test, compression test, Gaenslen's test, distraction test, Patrick's sign, posterior provocation test).
F) Absence of generalized pain behavior (e.g. somatoform disorder) and generalized pain disorders (e.g. fibromyalgia).
G) Diagnostic imaging studies that include ALL of the following:  
1) Imaging (plain radiographs and a CT or MRI) of the SIJ that excludes the presence of destructive lesions (e.g. tumor, infection), fracture, traumatic sacroiliac joint instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion 
2) Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology 
3) Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that can be causing low back or buttock pain 
4) Imaging of the SIJ that indicates evidence of injury and/or degeneration
H) At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits each with a different duration of action), and the ability to perform previously painful maneuvers, following an image-guided, contrast-enhanced intra-articular SIJ injection.
Otherwise, SIJ fusion is included on Line 517.
GUIDELINE NOTE 162, LONG-ACTING REVERSIBLE CONTRACEPTIVE (LARC) PLACEMENT
Line 6
Long-acting reversible contraceptives (implant or intrauterine device) are included on Line 6 in all settings, including (but not limited to) immediately postpartum and postabortion.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 163, SKIN SUBSTITUTES FOR CHRONIC SKIN ULCERS
Line 376
Skin substitutes for chronic venous leg ulcers and chronic diabetic foot ulcers are included on this line when all of the following criteria are met:
A) FDA indications and contraindications are followed, if applicable
B) Wound has adequate arterial flow (ABI > 0.7), no ongoing infection and a moist wound healing environment
C) For patients with diabetes, Hba1c level is < 12
D) Prior appropriate wound care therapy (including but not limited to appropriate offloading, multilayer compression dressings and smoking cessation counseling) has failed to result in significant improvement (defined as at least a 50 percent reduction in ulcer surface area) of the wound over at least 30 days 
E) Ongoing coverage requires significant improvement of the ulcer with skin substitute application over the preceding 6 week time period 
F) Patients is able to adhere to the treatment plan 
G) The use of skin substitutes is not included on this line for chronic skin ulcers other than venous leg ulcers and diabetic foot ulcers (e.g., pressure ulcers)
Note: There is no evidence supporting superiority of one skin substitute versus another and new studies are constantly being published.  Decisions for specific products could be made based on at least one supportive randomized controlled trial, and those that involve fewer applications, and are lower cost. 
GUIDELINE NOTE 164, PERCUTANEOUS REPAIR OF PARAVALVULAR LEAKS
Line 283
Percutaneous transcatheter closure of paravalvular leak (CPT *93590-93592) is included on this line only for patients with:
GUIDELINE NOTE 164, PERCUTANEOUS REPAIR OF PARAVALVULAR LEAKS (CONT'D)
A) prosthetic heart valves with paravalvular leak AND
B) intractable hemolysis or NYHA class III/IV heart failure AND
C) who are at high risk for surgery and have anatomic features suitable for catheter-based therapy AND
D) when performed in centers with expertise in the procedure.
GUIDELINE NOTE 165, FECAL MICROBIOTA TRANSPLANT
Line 146
Fecal microbiota transplant (FMT); (CPT *44705, HCPCS G0455) is included on this line for treatment of recurrent C difficile infection only.
GUIDELINE NOTE 166, BREAST REDUCTION SURGERY FOR SYMPTOMATIC MACROMASTIA
Lines 400,547
Breast reduction surgery is included on Lines 400, 415 and 424 only when ALL of the following conditions are met:
A) The patient is aged 15 or older; AND
B) The patient has a diagnosis of macromastia (size D or higher); AND
C) At least one of the following criteria (1 or 2) have been met: 
1) Back, neck or shoulder pain
a) Must be documented to have adverse effects on activities of daily living
b) Must be unresponsive to conservative treatments for three months within a year prior. Conservative treatment must include at least three months of:
i) a documented trial of analgesics, AND
ii) physical therapy or chiropractic/osteopathic manipulation treatment or acupuncture, AND
iii) use of support wear for the breast; OR
2) Persistent severe intertrigo in the inframammary fold unresponsive to documented prescribed medication for at least three months within a year prior; AND
D) The treating surgeon must document that breast reduction has a high likelihood of improving the symptoms that limit activities of daily living caused by the macromastia; AND
E) The expected bilateral reduction volume must be greater than 300 grams (1 cup size) per breast; AND
F) Women aged 40 and older are required to have a negative screening mammogram within two years of the planned reduction mammoplasty; AND
GUIDELINE NOTE 166, BREAST REDUCTION SURGERY FOR SYMPTOMATIC MACROMASTIA (CONT'D)
G) Member should be a non-smoker or should not have smoked within the 6 weeks prior to surgery as documented by the surgeon.
Additional criteria for patients aged 15-17 years:
A) The patient must have completed puberty (Tanner stage V)
B) The patient must have a one year history of growth stabilization evidenced by a minimum of four visits with documented heights or puberty completion as shown on wrist radiograph read by a radiologist.
Otherwise, breast reduction surgery is included on Line 547.
GUIDELINE NOTE 167, CHOLECYSTECTOMY FOR CHOLECYSTITIS AND BILIARY COLIC
Lines 55,623
Cholecystectomy for cholecystitis and biliary colic are including on Line 55 when meeting the following criteria:
A) For cholecystitis, with the presence of right upper quadrant abdominal pain, mass, tenderness, or a positive Murphy's sign, AND EITHER:
1) Evidence of inflammation (e.g. fever, elevated white blood cell count, elevated C reactive protein) OR 
2) Ultrasound findings characteristic of acute cholecystitis or non-visualization of the gall bladder on oral cholecystegram or HIDA scan, or gallbladder ejection fraction of less than 35% or greater than 80%.
B) For biliary colic without evidence of cholecystitis or other complications only when 
1) Recurrent (i.e. 2 or more documented clinical encounters with an exam consistent with gallstone induced pain in a one year period with at least one imaging study demonstrating gallstones) OR
2) A single episode in a patient at high risk for complications with emergent cholecystitis (e.g. immunocompromised patients, morbidly obese patients, diabetic patients) OR
3) When any of the following are present: elevated pancreatic enzymes, elevated liver enzymes or dilated common bile duct on ultrasound.
Otherwise, biliary colic is included on Line 623.
GUIDELINE NOTE 167, CHOLECYSTECTOMY FOR CHOLECYSTITIS AND BILIARY COLIC (CONT'D)
ICD-10-CM K82.8 (Other specified diseases of gallbladder) is included on Line 55 when the patient has porcelain gallbladder or gallbladder dyskinesia with a gallbladder ejection fraction less than 35% or hyperkinetic biliary dyskinesia with gallbladder ejection fraction greater than 80% AND meets above criteria. Otherwise, K82.8 is included on Line 623.
Cholecystectomy is included on Line 55 for ICD-10-CM K82.4 (Cholesterolosis of gallbladder) when one of the following conditions are met:
A) The polyp measures 10 mm or larger; OR
B) The polyp measures 6-9 mm with one or more of the following risk factors for malignancy:
1) Age over 60 years; OR
2) History of primary sclerosing cholangitis; OR
3) Asian ethnicity; OR
4) Sessile polypoid lesion, including focal gallbladder wall thickening of greater than 4 mm.
Otherwise, ICD-10-CM K82.4 is included on Line 623.
GUIDELINE NOTE 168, INTRASTROMAL CORNEAL RING SEGMENTS
Line 307
Insertion of intrastromal corneal ring segments (CPT *65785) is included on this line only for reduction or elimination of myopia or astigmatism in adults age 19 and older with keratoconus who are no longer able to achieve adequate functional vision to perform ADLs with best correction using contact lenses or spectacles, who have a corneal thickness of 450 microns or greater at proposed incision site, and for whom corneal transplant is the only remaining option to improve their functional vision.
GUIDELINE NOTE 169, ORTHODONTICS FOR CRANIOFACIAL ANOMALIES AND HANDICAPPING MALOCCLUSION
Lines 254,600
Orthodontic treatment is included on Line 254 DEFORMITIES OF HEAD AND HANDICAPPING MALOCCLUSION for persons under the age of 21 with:
GUIDELINE NOTE 169, ORTHODONTICS FOR CRANIOFACIAL ANOMALIES AND HANDICAPPING MALOCCLUSION (CONT'D)
A) Cleft lip and palate, cleft palate or cleft lip with alveolar process involvement, OR
B) Other craniofacial anomalies resulting in significant malocclusion expected to result in difficulty with mastication, speech, or other oral function, OR
C) Severe malocclusions with a Handicapping Labiolingual Deviation Index California Modification score of 26 or higher; AND
D) Free and clear of active decay and periodontal disease, verified by a dental exam in past 6 months
Advanced dental imaging is included on this line only when required for surgical planning for repair of craniofacial anomalies and handicapping malocclusion.
All other orthodontic services appear on Line 600 DENTAL CONDITIONS (E.G., MALOCCLUSION).
GUIDELINE NOTE 170, INTRATHECAL OR EPIDURAL DRUG INFUSION
Lines 71,283,290
Implantation, revision and replacement of devices for intrathecal or epidural drug infusion systems is only included on these lines when the patient meets the criteria for at least one of the categories (A or B) below:
A) Placed for administration of baclofen for spasticity where all of the following (1-3) occur:
1) The patient has had an adequate trial of non-invasive methods of spasticity control and not had adequate control of spasticity or had intolerable side effects with these methods. 
2) The spasticity is causing difficulties with at least one of the following (a, b or c):
a) Posture or function
b) Balance or locomotion
c) Self-care (or ease of care by parents or caregivers)
3) The patient has a favorable response to a trial intrathecal dosage of the anti-spasmodic drug prior to pump implantation.
B) Palliation for severe, intractable pain due to life-limiting active cancer which 
1) Has not been responsive to non-invasive systemic pain control strategies or had intolerable side effects from such strategies, AND 
GUIDELINE NOTE 170, INTRATHECAL OR EPIDURAL DRUG INFUSION (CONT'D)
2) Where the patient has a favorable response to a trial of an intrathecal dose of the analgesic drug prior to pump implantation
Intrathecal or epidural drug infusion pump insertion, revision, and replacement are included on Excluded Services Guideline 2 for use with chronic non-malignant pain and all other indications not listed above. Removal of pumps placed for such indications is included on Line 283.
Maintenance (i.e. reprogramming, medication refill) of epidural or intrathecal medication infusion pumps for any condition is only included on these lines for patients who 
A) have no significant complications with the current medication regimen or pump delivery system AND
B) are continuing to receive adequate benefit from the pump-delivered medication.
Maintenance (but not replacement) of these infusion systems may be paired with ICD-10-CM Z45.49 (Encounter for adjustment and management of other implanted nervous system device).
CPT codes 62320-62323 (Injection(s) of diagnostic or therapeutic substance(s) (e.g., anesthetic, antspasmodic, opioid, steriod, other solution), interlaminar epidural or subarachnoid) are only included on Lines 71 and 290 for trials of antispasmodics in preparation for placement of a baclofen pump.
GUIDELINE NOTE 171, LATTICE DEGENERATION, ASYMPTOMATIC RETINAL BREAKS AND ROUND HOLES
Lines 371,634
Lattice degeneration is included on Line 371 only for pairing with ophthalmologic visits and dilated eye exams, and only for patients at high risk of retinal detachment:
A) Patients under the age of 65 years with round holes and myopic vision, OR
B) Patients with a history of retinal detachment in the other eye OR,
C) Patients with biologic family member with history of retinal tear or retinal detachment
Otherwise, lattice degeneration is included on Line 634.
GUIDELINE NOTE 171, LATTICE DEGENERATION, ASYMPTOMATIC RETINAL BREAKS AND ROUND HOLES (CONT'D)
Retinal breaks and round holes are only included for pairing with treatment (other than ophthalmologic visits and dilated eye exams) on Line 371 when they are symptomatic, the result of trauma, or are horseshoe breaks.  Otherwise, these diagnoses are included on Line 634.
GUIDELINE NOTE 174, CRYOABLATION OF PULMONARY TUMORS
Line 260
Cryoablation of pulmonary tumors is included on this line only for palliative treatment of an inoperable lung tumor with one of the following:
A) Symptomatic proximal endobronchial obstruction, OR
B) Presence of endobronchial lesion with associated lobar or greater parenchymal atelectasis, OR
C) Hemoptysis from endobronchial location of the tumor.
GUIDELINE NOTE 175, MEDICATION-ASSISTED TREATMENT OF OPIOID DEPENDENCE 
Lines 1,4
In patients who meet criteria for opioid use disorder, programs that offer treatment of opioid use disorder must offer patients a variety of evidence-based interventions including behavioral interventions, social support, and Medication Assisted Treatment (MAT) and are individualized to the patient's needs. Intensive programs, such as inpatient residential treatment programs, are required to inform patients about MAT and to offer access to and support for MAT (including at least one form of opioid substitution therapy) if patients elect to receive it, to be included on this line.  
MAT includes pharmacotherapy with opioid substitution therapy (methadone and buprenorphine) and opioid antagonists (naltrexone).
Detoxification alone is likely ineffective for producing long-term benefit and should be followed by a formal substance use disorder individualized treatment plan.
In pregnant women with opioid dependence, comprehensive treatment (including opioid substitution therapy) is included on this line.
GUIDELINE NOTE 176, OPPORTUNISTIC SALPINGECTOMY
Lines 1,6,25,37,51,61,63,133,237,284,296,350,392,402,419,421,428,455,466,468,519,544,567
Opportunistic salpingectomy is defined as the prophylactic removal of the fallopian tubes for the primary prevention of ovarian cancer when a woman is undergoing pelvic surgery for another indication, or instead of a bilateral tubal ligation (BTL) for the purpose of sterilization.  It is included on these lines when used for these purposes, however, no additional payment is intended beyond the cost of the indicated pelvic surgery (e.g. using reference-based pricing) or the cost of the BTL and as long as the addition of the opportunistic salpingectomy does not result in a change in setting (for example requiring a hospital setting versus ambulatory surgery center).
Opportunistic salpingectomy should be paired with Z40.03 (Encounter for prophylactic removal of fallopian tube(s)) or Z30.2 (Encounter for sterilization).
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 178, SPINAL CORD STIMULATOR THERAPY 
Lines 290,343,517
A spinal cord stimulator trial is included on Lines 290 and 343 only when a patient meets all of the following criteria:
A) The patient has moderate to severe (>5 on the VAS pain scale) neuropathic pain and objective neurologic impairment with documented pathology related to pain complaint (i.e., abnormal MRI). Neurologic impairment is defined as objective evidence of one or more of the following:
1) Markedly abnormal reflexes
2) Segmental muscle weakness
3) Segmental sensory loss
4) EMG or NCV evidence of nerve root impingement
5) Cauda equina syndrome
6) Neurogenic bowel or bladder
7) Long tract abnormalities; AND
GUIDELINE NOTE 178, SPINAL CORD STIMULATOR THERAPY (CONT'D)
B) The patient has failed 12 or more months of other treatment modalities (e.g., pharmacological, surgical, physical therapy, cognitive therapy, and activity lifestyle modification); AND
C) The patient has had an evaluation by a mental health provider (e.g., a face-to-face assessment with or without psychological questionnaires and/or psychological testing) which revealed no evidence of an inadequately controlled mental health problem (e.g., alcohol or drug dependence, depression, psychosis) and the patient receives written clearance from the mental health provider for device placement. 
Implantation of a spinal cord stimulator is included on Lines 290 and 343 when the trial criteria above are met and the patient experienced significant pain reduction (50% or more) with a 3-to-7-day trial of percutaneous spinal stimulation.
Spinal cord stimulation (CPT *63650-63688) is not included on Line 290 when paired with ICD-10-CM category G90.5 Complex regional pain syndrome/reflex sympathetic dystrophy.
Replacement of a spinal cord stimulator is included on Lines 290 and 343 only for patients who:
A) meet the criteria for initial insertion above; AND
B) have experienced significant pain reduction (50% or more) with the stimulator prior to its malfunction; AND
C) and the existing stimulator is no longer under warranty and cannot be repaired.
Otherwise, spinal cord stimulation therapy is included on Line 517.
GUIDELINE NOTE 179, DIABETES PREVENTION PROGRAM
Line 3
Prediabetes (R73.03) and personal history of gestational diabetes (Z86.32) are included on this line only for the Diabetes Prevention Program (DPP).  The only programs included are CDC-recognized lifestyle change programs for DPP.
To be eligible for referral to a CDC-recognized lifestyle change program, patients must meet ALL of the following requirements (A-E):
A) Be at least 18 years old; AND
GUIDELINE NOTE 179, DIABETES PREVENTION PROGRAM (CONT'D)
B) Be overweight (body mass index greater than or equal to 25; greater than or equal to 23 if Asian; BMI percentile greater than or equal to 85th percentile for 18-19 years old); AND 
C) Have no current diagnosis of type 1 or type 2 diabetes; AND
D) Not have end-stage renal disease; AND
E) Meet one of the two criteria below:
1) Have a blood test result in the prediabetes range within the past year:
a) Hemoglobin A1C: 5.7%-6.4% or
b) Fasting plasma glucose: 100-125 mg/dL or
c) Two-hour plasma glucose (after a 75 gm glucose load): 140-199 mg/dL or
2) Have a previous diagnosis of gestational diabetes
GUIDELINE NOTE 180, MEDICALLY INDICATED CIRCUMCISION
Lines 21,324,411,489
Circumcision (CPT *54150, 54160, 54161) is included on these lines only for patients with
A) Balanitis xerotica obliterans, or
B) Recurrent balanoposthitis (2 or more bouts, not balanitis), or
C) Severe foreskin scarring causing physiologic complications, or
D) Vesicoureteric reflux (grade 2 or higher) or other urologic abnormalities, or
E) Recurrent urinary tract infections (2 or more with documented positive urine cultures).
Balanitis (ICD-10-CM N48.1) does not pair with circumcision.
Circumcision for phimosis (ICD-10-CM N47.1) is only medically necessary when
A) The patient is Tanner stage 4 or 5; AND
B) Corticosteroid therapy has been tried and is not effective; AND
C) The patient has voiding problems, recurrent balanitis, recurrent urinary tract infections, or balanitis xerotica.
Otherwise, ICD-10-CM N47.1 is included on Line 489.
GUIDELINE NOTE 181, POSTPARTUM DEPRESSION SCREENING
Line 3
Postpartum depression screening using a validated instrument (e.g. Edinburgh Postpartum Severity Score, PHQ-9) is included on this line during the child's visit (CPT *96161) or during the mother's visit (CPT *96160, 96127) when there is a plan in place to address positive depression screens.
GUIDELINE NOTE 182, TESTOSTERONE REPLACEMENT FOR TESTICULAR HYPOFUNCTION
Line 468
Testosterone replacement therapy is included on this line for testicular hypofunction or dysfunction only when all of the following inclusion criteria are met and none of the exclusion criteria apply:
Inclusion criteria:
A) The patient is a male 18 years of age or older; AND
B) The patient has had TWO morning (between 8 a.m. to 10 a.m.) tests (at least 1 week apart) at baseline demonstrating low testosterone levels as defined by the following criteria:
1) Total serum testosterone level less than 300ng/dL (10.4nmol/L); OR
2) Total serum testosterone level less than 350ng/dL (12.1nmol/L) AND free serum testosterone level less than 50pg/mL (or 0.174nmol/L); AND
C) Patient has received ONE of the following diagnoses:
1) Primary Hypogonadism (congenital or acquired): as defined as testicular failure due to such conditions as cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchidectomy, Klinefelter's syndrome, chemotherapy, trauma, or toxic damage from alcohol or heavy metals; OR
2) Hypogonadotropic Hypogonadism (congenital or acquired): as defined by idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency, or pituitary-hypothalamic injury from tumors, trauma or radiation
Exclusion criteria:
A) Patient has ANY of the following contraindications:
1) Breast cancer or known or suspected prostate cancer 
2) Elevated hematocrit (>50%) 
GUIDELINE NOTE 182, TESTOSTERONE REPLACEMENT FOR TESTICULAR HYPOFUNCTION (CONT'D)
3) Untreated severe obstructive sleep apnea 
4) Severe lower urinary tract symptoms 
5) Uncontrolled or poorly-controlled heart failure 
B) Patient has experienced a major cardiovascular event (such as a myocardial infraction, stroke, acute coronary syndrome) in the past six months
C) Patient has uncontrolled or poorly-controlled benign prostate hyperplasia or is at a higher risk of prostate cancer, such as elevation of PSA after initiating testosterone replacement therapy
This guideline does not apply to testosterone replacement therapy for HIV-associated weight loss, delayed puberty, treatment of metastatic breast cancer, or transgender health.
GUIDELINE NOTE 183, DONOR BREAST MILK FOR HIGH-RISK INFANTS
Lines 16,34,87,100
Donor breast milk (HCPCS T2101) is included on these lines for infants up to 6 months of age (adjusted for gestational age) who meet all of the following criteria:
* Low birth weight (<1500g) or with severe underlying gastrointestinal disease 
* Human donor milk was continued through neonatal hospital discharge for a clear medical indication
* Persistent outpatient medical need for human donor breast milk 
* When maternal breast milk is not available, appropriate or sufficient to meet the infant's needs, despite lactation support for the mother.  
* Donor human milk may only be obtained through a milk bank with accreditation from the Human Milk Banking Association of North America (HMBANA).
GUIDELINE NOTE 184, MRGFUS FOR ESSENTIAL TREMOR
Line 359
Magnetic resonance image guided high intensity focused ultrasound (MRgFUS) is only covered for essential tremor and only when ALL of the following conditions are met:
A) The essential tremor has failed to adequately respond to at least two trials of medication therapy or the patient is unable to tolerate two types of first line treatment options due to side effects; AND
GUIDELINE NOTE 184, MRGFUS FOR ESSENTIAL TREMOR (CONT'D)
B) The tremor is moderate to severe (defined by a score of = 2 on the Clinical Rating Scale for Tremor [CRST]) affecting the dominant hand; AND
C) The tremor affects the patient's activities of daily living (defined by a score of =2 on any of the eight items in the disability subsection of the CRST or another nationally accepted clinical measure of tremor severity); AND
D) The patient is not a candidate for deep brain stimulation (DBS), or has failed DBS, but has no retained cranial implants. 
MRgFUS is not covered for tremor related to Parkinson's disease or for any other intracranial indication.
GUIDELINE NOTE 185, YTTRIUM-90 THERAPY
Line 312
Yttrium 90 therapy is only included on this line for treatment of hepatocellular carcinoma (HCC) and only when recommended by a multidisciplinary tumor board or team in the following circumstances:
A) Downsizing tumors in patients who could become eligible for curative treatment (transplant, ablation, or resection), OR
B) Palliative treatment of incurable patients with unresectable or inoperable tumors that are not amenable to ablation therapy and 
1) who have good liver function (Child-Pugh class A or B) and 
2) good performance status (ECOG performance status 0-2), and
3) who have intermediate stage disease with tumors > 5 cm OR advanced stage HCC with unilateral (not main) portal vein tumor thrombus
Pretreatment mapping is included on this line, however, pre-treatment embolization is not included on this line due to insufficient evidence of effectiveness.
GUIDELINE NOTE 186, TRANSORAL INCISIONLESS FUNDOPLICATION FOR TREATMENT OF GERD
Line 377
Transoral incisionless fundoplication (TIF), CPT *43210, utilizing the EsophyX device only, is included on Line 377 for surgical treatment of GERD only when the patient meets ALL the following criteria (A-F):
A) 18 years of age or older; 
B) Confirmed diagnosis of esophageal reflux by endoscopy, ambulatory pH, or barium swallow testing; 
C) History of GERD symptoms for one year, occurring at least two to three times per week in the past month; 
D) History of daily proton pump inhibitor therapy for the most recent six months; 
E) Body mass index (BMI) 35 or lower, 
F) Absence of ALL of the following conditions
1) Hiatal hernia larger than 2 cm
2) Severe esophagitis, for example LA grade of C or D
3) Barrett's esophagus greater than 2 cm
4) Achalasia
5) Esophageal ulcer
6) Esophageal motility disorder
7) Altered esophageal anatomy preventing insertion of the device
8) Previous failed anti-reflux surgery or procedure
Repeat TIF is not included on Line 377 for patients who have recurrent symptoms or fail the initial TIF procedure.
GUIDELINE NOTE 187, PULMONARY REHABILITATION
Lines 9,58,221,232,239,281
Pulmonary rehabilitation is included on these lines only for patients with ALL of the following (A-D):
A) Moderate to severe chronic pulmonary disease with dyspnea with exertion that reduces their ability to perform activities of daily living despite appropriate medical management,
1) Moderate to severe pulmonary disability defined as either
GUIDELINE NOTE 187, PULMONARY REHABILITATION (CONT'D)
2) A maximal pulmonary exercise stress test under optimal bronchodilatory treatment which demonstrates a respiratory limitation to exercise with a maximal oxygen uptake (VO2max) equal to or less than 20 ml/kg/min, or about 5 metabolic equivalents (METS); or
B) Pulmonary function tests showing that either the forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, or diffusion capacity for carbon monoxide (Dlco) is less than 60% of that predicted; 
C) Physically able, motivated and willing to participate in the pulmonary rehabilitation program and be a candidate for self-care post program; 
D) No contraindications to pulmonary rehabilitation, including unstable cardiac disease, locomotor or neurological difficulties precluding exercise, significant cognitive or psychiatric impairment, or housebound due to the severity of disease.
Pulmonary rehabilitation is only covered for:
A) A multidisciplinary program with includes supervised exercise therapy, patient education, and smoking cessation (if applicable).
B) Up to 36 total sessions.
Repeat pulmonary rehabilitation programs should be limited to those patients who have had a subsequent lung reduction surgery or lung transplantation.
GUIDELINE NOTE 189, EMBOLIZATION OF ARTERIAL MALFORMATIONS
Line 303
Vascular embolization or occlusion of arterial or arteriovenous malformations is included on this line only for Schobinger Class 3 or 4 lesions.
GUIDELINE NOTE 190, SHOULDER DECOMPRESSION SURGERY
Lines 353,415,441
CPT *29826 is only included on these lines as a component of rotator cuff repair surgery. CPT *29826 is not included on this line for pairing with shoulder impingement syndrome or adhesive capsulitis of shoulder. 
GUIDELINE NOTE 191, REPAIR OF VARICOCELES IN CHILDREN AND ADOLESCENTS
Lines 324,534
Varicocele repair is only included on Line 324 for children and adolescents (up through age 18) with:
A) Pain affecting activities of daily living from the varicocele; OR
B) Objective evidence of reduced ipsilateral testicular size of 20% of more compared to the contralateral testicle; OR
C) Varicocele in a patient with a solitary testicle.
All other varicocele repair is included on Line 534.
GUIDELINE NOTE 192, SACRAL NERVE STIMULATION FOR URINARY CONDITIONS
Lines 324,455
Sacral nerve stimulation is included on these lines only for urinary incontinence, non-obstructive urinary retention, and overactive bladder AND only when all of the following criteria are met:
A) The patient has had symptoms for at least 12 months and the condition has resulted in significant disability (the frequency and/or severity of symptoms are limiting the member's ability to participate in daily activities); AND
B) Documented failure or intolerance to pharmacotherapies and behavioral treatments (e.g., pelvic floor exercise, timed voids, and fluid management) and, for non-obstructive urinary retention, intermittent catheterization; AND
C) The patient must be an appropriate surgical candidate such that implantation with anesthesia can occur; AND
D) The patient does not have stress incontinence, urinary obstruction, or specific neurologic diseases (e.g., diabetes with peripheral nerve involvement, spinal cord injury, or multiple sclerosis); AND
E) Patient must have had a successful test stimulation, defined as a 50% or greater improvement in symptoms.
GUIDELINE NOTE 193, ARTIFICIAL URINARY SPHINCTERS
Line 455
Artificial urinary sphincters are included on this line only for patients with intrinsic sphincter deficiency with any of the following indications:
GUIDELINE NOTE 193, ARTIFICIAL URINARY SPHINCTERS (CONT'D)
A) Children with intractable urinary incontinence due to intrinsic sphincter deficiency who are refractory to behavioral or pharmacological therapies and are unsuitable candidates for other types of surgical procedures for correction of urinary incontinence; OR
B) Patients who are 6 or more months post-prostatectomy who have had no improvement in the severity of urinary incontinence despite trials of behavioral and pharmacological therapies; OR
C) Men with epispadias-exstrophy in whom bladder neck reconstruction has failed; OR
D) Women with intractable urinary incontinence who have failed behavioral, pharmacological, and other surgical treatments.
GUIDELINE NOTE 194, PHRENIC NERVE STIMULATION
Line 71
Phrenic nerve stimulation is included on this line when all of the following criteria are met:
A) The patient has severe, chronic respiratory failure requiring mechanical ventilation due to EITHER
1) A stable high spinal cord injury defined as C3 or above; OR
2) Central hypoventilation disorder; AND
B) The patient has intact and sufficient function in the phrenic nerve, lungs, and diaphragm; AND 
C) Stimulation of the diaphragm either directly or through the phrenic nerve results in sufficient muscle activity to accommodate independent breathing without the support of a ventilator for at least 4 continuous hours per day.
GUIDELINE NOTE 195, TEMPORARY PERCUTANEOUS MECHANICAL CIRCULATORY SUPPORT WITH IMPELLA DEVICES
Line 69
Temporary percutaneous mechanical circulatory support with Impella devices is included on Line 69 only in the two following circumstances:
1) During percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) when all of the following conditions are met:
* ACS without cardiogenic shock (STEMI, NSTEMI or unstable angina)
GUIDELINE NOTE 195, TEMPORARY PERCUTANEOUS MECHANICAL CIRCULATORY SUPPORT WITH IMPELLA DEVICES (CONT'D)
* A heart team discussion determines the patient needs revascularization with coronary artery bypass graft (CABG) or PCI
* A cardiothoracic surgeon is consulted and agrees the patient is inoperable (i.e., are not willing to perform CABG but agree revascularization is indicated)
* Patient has complex left main or last remaining conduit disease
* Ejection fraction (EF) < 30% or at high risk for hemodynamic collapse during intervention 
2) In patients with cardiogenic shock.
Temporary percutaneous mechanical circulatory support with Impella devices is not included on this or any other line for elective high-risk PCI for patients with stable coronary artery disease.
GUIDELINE NOTE 196, BREAST SURGERY REVISION
Lines 190,283,309,422,547,618,624
Revision of previous breast reconstruction, augmentation, or other breast surgery is only covered in cases where the revision is required to address complications of the surgery (wound dehiscence, fistula, chronic pain directly related to the surgery, etc.). For capsular contracture, only stage 4 contractures with chronic pain are covered for revision surgery/capsulotomy. Revisions of breast reconstruction, augmentation or other breast surgery are not covered solely for cosmetic issues.
GUIDELINE NOTE 197, COUNSELING FOR PREGNANT AND POSTPARTUM WOMEN
Lines 1,3,35,63
Counseling for the prevention of peripartum mood disorders for pregnant and postpartum women (including up to 1 year after birth or pregnancy loss) are included on these lines according to USPSTF recommendations https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/perinatal-depression-preventive-interventions and should be coded with health behavior assessment and intervention procedure codes.
GUIDELINE NOTE 198, HIDRADENITIS SUPPURATIVA
Lines 416,502
Hidradenitis suppurativa is included on Line 416 only for moderate to severe disease (e.g. Hurley Stage II or Hurley Stage III); otherwise this condition is included on Line 502.
Initial treatment with targeted immune modulators is limited to adults whose disease has not responded to at least a 90-day trial of conventional therapy (e.g., oral antibiotics), unless such a trial is not tolerated or contraindicated. Treatment with targeted immune modulators after the initial trial is only included on Line 416 for patients with a clear evidence of response, defined as:
A) a reduction of 25% or more in the total abscess and inflammatory nodule count, AND
B) no increase in abscesses and draining fistulas.
GUIDELINE NOTE 199, SUPRACHOROIDAL INJECTION
Line 357
Suprachoroidal space injection (CPT *67516) is only included on this line for treatment of macular edema associated with uveitis with triamcinolone acetonide.
GUIDELINE NOTE 200, SURGERIES RELATED TO FEMALE GENITAL MUTILATION
Line 120
Female genital mutilation of children or adults is not included on any line on the Prioritized List, including returning a woman to her former status after delivery.
Repair of female genital mutilation (e.g. Type II or III) with defibulation or lysis of adhesions is included on this line when causing interference in function (i.e. urinary, menstrual, or potential future vaginal childbirth) or causing recurrent complications including chronic pain related to the mutilation. Clitoral reconstruction is not included on this line due to an unclear risk/benefit ratio.
GUIDELINE NOTE 201, TETHERED CORD 
Lines 343,517
Surgical repair of tethered cord is included on Line 343 for patients when the following conditions are met: 
A) Symptoms:
GUIDELINE NOTE 201, TETHERED CORD (CONT'D)
1) Infants and pre-walking/toilet trained children with cutaneous markers or orthopedic deformities; OR
2) Children and adults with bladder and bowel incontinence of neurologic origin AND/OR sensorimotor lower extremity deficits; AND
B) Imaging:
1) Ultrasound findings consistent with tethered cord for infants up to 3 months; OR 
2) MRI findings consistent with tethered cord (i.e. conus termination below the L2 vertebral body, intradural or extradural lipoma, lipomeningocele, lipomyelomeningocele, split cord malformation, low conus termination at the L2 vertebral body with thickened non-fatty filum in a symptomatic patient, or previous myelomeningocele repair or other spinal surgery resulting in fibrous adhesions).
Surgery for tethered cord in patients not meeting the above criteria are included on Line 517.
GUIDELINE NOTE 202, MAGNETOENCEPHALOGRAPHY
Line 173
Magnetoencephalography (MEG) is included on this line only for pre-surgical evaluation in persons with intractable focal epilepsy to identify and localize areas of epileptiform activity, when discordance or continuing questions arise from among other techniques designed to localize a focus.
GUIDELINE NOTE 203, FOOD ALLERGY TREATMENT
Line 123
ICD-10-CM T78.0 family (Anaphylactic reaction due to foods) are included on Line 123 for 
A) Office visit, specialist consultation, ER evaluation/treatment, and hospital care; and
B) Symptomatic treatment with medications such as antihistamines or epinephrine; and 
C) Pharmaceutical treatment with medications intended to reduce the severity of the food allergy only when ALL of the following criteria are met:
1) The patient has a clinical history of serious food allergy with anaphylaxis, AND
2) The diagnosis of food allergy has been confirmed with an IgE or skin-prick test, AND
3) The pharmaceutical treatment is prescribed by, or in consultation with, an allergist or immunologist.
GUIDELINE NOTE 204, NERVE ALLOGRAFTS
Line 524
Nerve allografts (CPT *64912-64913) are only on this line for repair of digital nerve injury (ICD-10-CM S64.4 code category). 
GUIDELINE NOTE 205, DEVELOPMENTAL DELAY CODING
Lines 290,342,374,641
ICD-10-CM R62.0 and R62.50 are included on these lines for children 5 and under used to identify dysfunction substantially below chronological age, when significantly and persistently interfering with activities of daily living appropriate for chronological age, and there is an opportunity for skill learning. ICD-10-CM F88 is included on these lines for developmental delay. When it is used to indicate sensory integration disorder or sensory processing disorder, it is included on Line 641.
GUIDELINE NOTE 206, PANNICULECTOMY
Line 607
Panniculectomy (CPT *15830, 15847) is included on this line when ALL of the following conditions are met:
A) The pannus hangs at or below the level of the symphysis pubis as evidence by photographs; AND
B) The pannus is causing persistent intertriginous dermatitis, cellulitis, or skin ulceration, which is refractory to at least three months of medical management, including topical antifungals, topical and/or systemic corticosteroids, and/or local or systemic antibiotics; AND
C) There is documented difficulty with ambulation and/or interference with the activities of daily living due to the pannus.
If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least six months. If the weight loss is the result of bariatric surgery, panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent six months.
GUIDELINE NOTE 206, PANNICULECTOMY (CONT'D)
Panniculectomy is not included on this line for any other indication, including but not limited to when performed primarily for ANY of the following:
A) Treatment of neck or back pain; OR
B) Improving appearance (i.e., cosmesis); OR
C) Treating psychological symptomatology or psychosocial concerns; OR
D) When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy are met separately.
GUIDELINE NOTE 207, OTHER INTESTINAL MALABSORPTION
Lines 226,539
ICD-10-CM K90.89 (Other intestinal malabsorption) is included on this line only for chronic steatorrhea, exudative enteropathy, and protein-losing enteropathy. Otherwise, it is included on Line 539.
GUIDELINE NOTE 208, CARCINOMA IN SITU OF PENIS
Line 256
CPT *96567-96573 (Photodynamic therapy) and 96574 (Debridement of premalignant hyperkeratotic lesion) are included on this line only for pairing with ICD-10-CM D07.4 (Carcinoma in situ of penis). 
GUIDELINE NOTE 209, COMPRESSION OF VEIN
Lines 260,621
ICD-10-CM I87.1 (Compression of vein) is included on Line 260 for superior vena cava syndrome only. Otherwise, it is included on Line 621.
GUIDELINE NOTE 210, CATHETER DIRECTED THROMBOLYSIS
Line 278
Catheter directed thrombolysis (CPT *37212-37214) is not paired on this line with peripheral DVT (ICD-10-CM I82.6, I82.7, I82.A, I82.B, I82.8, I82.9).
GUIDELINE NOTE 211, BENIGN NEOPLASM OF PAROTID GLAND
Lines 285,609
ICD-10-CM D11.0 (Benign neoplasm of parotid gland) is included on Line 285 only for parotid gland pleomorphic adenomas.  Otherwise, it is included on Line 609.
GUIDELINE NOTE 212, KNEE ARTHROSCOPY
Line 353
Knee arthroscopy (CPT *29871, 29873-29876, 29884-29887) is not included on this line when paired with osteoarthritis/osteoarthrosis of the knee (ICD-10-CM M17.0-M17.9).
GUIDELINE NOTE 214, IMPLANTATION OF INTRAVITREAL DRUG DELIVERY SYSTEM
Line 380
CPT *67027 (Implantation of intravitreal drug delivery system) is included on this line for use with medications other than intraocular steroid implants.
GUIDELINE NOTE 215, ORTHOPTIC AND/OR PLEOPTIC TRAINING
Line 390
CPTs 92065 and 92066 (Orthoptic and/or pleoptic training) are included on Line 390 only for pairing with ICD-10-CM H50.31 (Intermittent monocular esotropia), H50.32 (Intermittent alternating esotropia), H50.33 (Intermittent monocular exotropia), and H50.34 (Intermittent alternating exotropia).
GUIDELINE NOTE 216, RHINOPLASTY
Lines 42,119,201,244,285,309,464,495,512
Rhinoplasty is included on Line 309 for gender affirming treatment.
Rhinoplasty is included on Lines 42 and 119 when
A) It is performed to correct a nasal deformity secondary to congenital cleft lip and/or palate or other severe congenital craniofacial anomaly.
B) Rhinoplasty is included on Lines 227, 285, 495, 512 and 562 when it is performed as part of reconstruction after accidental or surgical trauma or disease (for example, Wegener's granulomatosis, nasal malignancy, abscess, septal infection with saddle deformity) AND
GUIDELINE NOTE 216, RHINOPLASTY (CONT'D)
1) There is prolonged, persistent obstructed nasal breathing unresponsive to a six-week trial of conservative management (e.g. nasal corticosteroids, decongestants, antibiotics); AND
2) Airway obstruction will not respond to septoplasty and turbinectomy alone; AND
3) Photographs demonstrate an external nasal deformity; AND
4) There is significant obstruction of one or both nares, documented by nasal endoscopy, computed tomography (CT) scan or other appropriate imaging modality.
C) Rhinoplasty is included on Line 464 when there is nasal airway obstruction causing chronic rhinosinusitis when all of the following are met:
1) The criteria for sinus surgery are met in Guideline Note 35, SINUS SURGERY; AND
2) Airway obstruction will not respond to septoplasty and turbinectomy alone; AND
3) Photographs demonstrate an external nasal deformity; AND
4) There is significant obstruction of one or both nares, documented by nasal endoscopy, computed tomography (CT) scan or other appropriate imaging modality
Care for acute nasal fractures (up to 14 days from the injury) is included on Line 227. Sequalae of nasal fractures, including nasal deformities, are included on Line 562.
GUIDELINE NOTE 217, PLANTAR FASCIA INJECTION
Line 526
CPT *20550 (Plantar fascia injection) only appears on this line for corticosteroid injections. The treatment is appropriate to the condition but has limited evidence of effectiveness.
GUIDELINE NOTE 218, CERVICOGENIC HEADACHE
Line 527
Osteopathic manipulative treatment and chiropractic manipulative treatment (CPT *98926-98929, 98940-98943) pair on this line only with cervicogenic headache (ICD-10-CM G44.86).
GUIDELINE NOTE 219, CHEMODENERVATION
Lines 290,324,348,359,375,391,408,490,505
Inclusion of chemodenervation on the Prioritized List has the following limitations for the lines specified below:
GUIDELINE NOTE 219, CHEMODENERVATION (CONT'D)
Line 290 NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS
Chemodenervation with botulinum toxin injection (CPT *64642-64647) is included on this line for treatment of upper and lower limb spasticity (ICD-10-CM codes G24.02, G24.1, G35, G36.0, I69.03- I69.06 and categories G71, and G80-G83)
Line 324 FUNCTIONAL AND MECHANICAL DISORDERS OF THE GENITOURINARY SYSTEM INCLUDING BLADDER OUTLET OBSTRUCTION
Chemodenervation of the bladder (CPT *52287) is included on this line only for treatment of idiopathic detrusor over-activity or neurogenic detrusor over-activity (ICD-10-CM N32.81) in patients who have not responded to or been unable to tolerate at least two urinary incontinence antimuscarinic or beta-3 adrenergic therapies (e.g. fesoterodine, oxybutynin, solifenacin, darifenacin, tolterodine, trospium, mirabegron, vibegron). Treatment is limited to 90 days, with additional treatment only if the patient shows documented positive response. Positive response to therapy is defined as a reduction of urinary frequency of 8 episodes per day or urinary incontinence of 2 episodes per day compared to baseline frequency.
Line 348 STRABISMUS DUE TO NEUROLOGIC DISORDER
Chemodenervation with botulinum toxin injection (CPT *67345) is included on this line for the treatment of strabismus due to other neurological disorders (ICD-10-CM H50.89).
Line 359 DYSTONIA (UNCONTROLLABLE); LARYNGEAL SPASM
Chemodenervation with botulinum toxin injection (CPT *64612, 64616) is included on this line only for treatment of blepharospasm (ICD-10-CM G24.5), spasmodic torticollis (ICD-10-CM G24.3), and other fragments of torsion dystonia (ICD-10-CM G24.9).
Line 375 ESOPHAGEAL STRICTURE; ACHALASIA
GUIDELINE NOTE 219, CHEMODENERVATION (CONT'D)
Chemodenervation with botulinum toxin injection (CPT *43201) is included on this line for treatment of achalasia (ICD-10 K22.0).
Line 391 ANAL FISTULA AND ANAL FISSURE
Chemodenervation with botulinum toxin injection (CPT *46505) is included on this line for the treatment of anal fissures that have been documented to have lasted longer than six weeks.
Line 408 MIGRAINE AND TENSION HEADACHES
Chemodenervation for treatment of chronic migraine (CPT *64615) is included on this line for prophylactic treatment of adults who meet all of the following criteria:
A) have chronic migraine defined as headaches on at least 15 days per month of which at least 8 days are with migraine
B) has not responded to or have contraindications to at least three prior pharmacological prophylaxis therapies (e.g. beta-blocker, anticonvulsant or tricyclic antidepressant)
C) their condition has been appropriately managed for medication overuse
D) treatment is administered in consultation with a neurologist or headache specialist.
Treatment is limited to two injections given 3 months apart. Additional treatment requires documented positive response to therapy. Positive response to therapy is defined as a reduction of at least 7 headache days per month compared to baseline headache frequency.
Line 490 SIALOLITHIASIS, MUCOCELE, DISTURBANCE OF SALIVARY SECRETION, OTHER AND UNSPECIFIED DISEASES OF SALIVARY GLANDS
Chemodenervation with botulinum toxin injection (CPT *64611) is included on this line for the treatment of excessive salivation.
GUIDELINE NOTE 219, CHEMODENERVATION (CONT'D)
Line 505 DISORDERS OF SWEAT GLANDS
Chemodenervation with botulinum toxin injection (CPT *64650, 64653) is included on this line for the treatment of axillary hyperhidrosis and palmar hyperhidrosis (ICD-10-CM L74.52, R61).
GUIDELINE NOTE 220, OSTEOCHONDRAL ALLOGRAFT/AUTOGRAFT TRANSPLANTATION (OAT) OF THE KNEE
Line 430
Osteochondral Allograft/Autograft Transplantation (OAT) is included on this line only when ALL of the following conditions are met:
A) The patient is younger than age 50; AND
B) There is no malignancy, degenerative or inflammatory arthritis in the joint; AND 
C) The patient has focal full thickness lesions (Grade III or IV) of the weight bearing surface with absent degenerative changes of the surrounding articular cartilage (Outerbridge grade II or less) and normal appearing cartilage around the defect; AND
D) The patient is not a candidate for total knee replacement; AND
E) The patient has failed standard conservative treatment including medication management and completed course of physical therapy; AND
F) The patient has normal knee alignment and stability
GUIDELINE NOTE 222, PARTIAL WRIST NEURECTOMY
Line 353
CPT *64772 is only included on this line for partial wrist neurectomy and is only covered when the alternative is wrist arthrodesis.
GUIDELINE NOTE 223, PERORAL ENDOSCOPIC MYOTOMY (POEM)
Line 375
Peroral endoscopic myotomy (POEM; CPT *43497) is included on this line only when ALL of the following criteria are met:
A) A diagnosis of esophageal achalasia type III (spastic) is established by the following:
1) Twenty percent (20%) or more of swallows have premature spastic contractions as indicated by esophageal manometry; AND
GUIDELINE NOTE 223, PERORAL ENDOSCOPIC MYOTOMY (POEM) (CONT'D)
2) Non-relaxing lower esophageal sphincter pressure (LES) indicated by a barium esophagogram with fluoroscopy and esophageal manometry; AND
B) Failure of a previous treatment for achalasia (e.g. Botox, pneumatic dilation); AND
C) None of the following contraindications are present:
1) Severe pulmonary disease; or
2) Esophageal irradiation; or
3) Esophageal malignancy; or
4) Bleeding disorder, including coagulopathy; or
5) Recent esophageal surgery; and endoscopic intervention
GUIDELINE NOTE 224, DECORONATION OR SUBMERGENCE OF AN ERUPTED TOOTH
Lines 381,409,442,454,496,525
Decoronation or submergence of an erupted tooth (CDT **D3921) is only included on these lines for teeth that would otherwise qualify for endodontic services included on these lines but for which endodontics cannot be performed due to high-risk circumstances (e.g. certain medications or radiation related osteonecrosis).
GUIDELINE NOTE 225, THERMAL ABLATION OF RENAL CELL CARCINOMA
Line 213
Thermal ablation (e.g., cryosurgery, radiofrequency ablation; CPT *50592, 50593) is included on this line only when:
A) The patient has biopsy-confirmed stage T1 renal cell cancer of <3 cm size; AND
B) The patient either has a surgically inoperable tumor(s) or is a poor candidate for standard treatments (i.e., nephrectomy).
GUIDELINE NOTE 226, DORSAL RHIZOTOMY FOR SPASTIC CEREBRAL PALSY
Line 290
Dorsal rhizotomy (CPT *63185 and 63190) is only included on this line for patients who meet ALL of the following criteria:
A) Has spastic diplegic cerebral palsy (ICD-10-CM G80.1); AND
B) Is a child aged 2 to 10 years; AND
C) Has good intrinsic lower extremity motor power, but is limited in ambulation by spasticity; AND
GUIDELINE NOTE 226, DORSAL RHIZOTOMY FOR SPASTIC CEREBRAL PALSY (CONT'D)
D) Has the functional capacity and motivation to participate in post-operative rehabilitation; AND
E) Has failed or been unable to tolerate other conservative treatment (e.g., pharmacotherapy, orthopedic management, physical therapy); AND
F) Has no contraindications to the procedure (e.g., significant scoliosis, progressive neurological disorders, severe fixed joint deformities)
GUIDELINE NOTE 227, GASTRIC ELECTRICAL STIMULATION
Lines 8,27,516
Gastric electrical stimulation (CPT *43647, 43648, 43881, 43882; HCPCS E0765) is included on these lines only for pairing with diabetic gastroparesis (ICD-10-CM E10.43, E11.43) or idiopathic gastroparesis (ICD-10-CM K31.84) and only when ALL of the following criteria are met:
A) The patient has intractable nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology; AND
B) The patient is refractory or intolerant of prokinetic medications and antiemetic medications; AND
C) The patient is not on opioid medications; AND
D) The patient does not have abdominal pain as the predominant symptom.
GUIDELINE NOTE 228, PANDAS, PANS AND AUTOIMMUNE ENCEPHALITIS
Lines 8,27,310,516
ICD-10-CM G04.82 (Other encephalitis and encephalomyelitis) is only included on this line for autoimmune encephalitis and related non-PANDAS/PANS conditions and is not included in this guideline. Autoimmune encephalitis must meet established diagnostic criteria (for example, the International Encephalitis Consortium 2013 diagnostic criteria).
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is included on this line when coded with ICD-10-CM D89.89 (Other specified disorders involving the immune mechanism, not elsewhere classified). Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) is included on this line when coded with ICD-10-CM D89.9 (Disorder involving the immune mechanism, unspecified).
GUIDELINE NOTE 228, PANDAS, PANS AND AUTOIMMUNE ENCEPHALITIS (CONT'D)
Up to 3 monthly immunomodulatory courses of intravenous immunoglobulin (IVIG) therapy is included on this line to treat PANDAS and PANS when both of the following are met:
A) A clinically appropriate trial of two or more less-intensive treatments (for example, appropriate limited course of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, selective serotonin reuptake inhibitors (SSRIs), behavioral therapy, short-course antibiotic therapy) was either not effective, not tolerated, or did not result in sustained improvement in symptoms (as measured by a lack of clinically meaningful improvement on a validated instrument directed at the patient's primary symptom complex). These trials may be done concurrently. Both trials of less intensive treatments must have occurred no more than 24 months prior to consideration of IVIG therapy; AND
B) A consultation with and recommendation from a pediatric subspecialist (for example, pediatric neurologist, pediatric psychiatrist, pediatric mental health nurse practitioner, neurodevelopmental pediatrician, pediatric rheumatologist, pediatric allergist/immunologist, as well as the recommendation of the patient's primary care provider (for example, family physician, pediatrician, pediatric or family nurse practitioner, family or pediatric physician assistant, naturopathic physician). The subspecialist consultation may be a teleconsultation. For adolescents, an adult subspecialist consult may replace a pediatric subspecialist consult. Specialist consultation must have occurred no more than 24 months prior to consideration of IVIG therapy.
A reevaluation at 3 months by both the primary care provider and pediatric expert is required for continued therapy of IVIG. This evaluation must include clinical testing with a validated instrument, which must be performed pretreatment and posttreatment to demonstrate clinically meaningful improvement.
Long term antibiotic therapy is not included on this line for treatment of PANDAS/PANS.
Therapeutic plasma exchange (CPT *36514) does not pair with PANDAS or PANS (ICD-10-CM D89.89 or D89.9).
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 229, HIGH-FREQUENCY CHEST WALL OSCILLATION DEVICES
Lines 20,58,71,196
High-frequency chest wall oscillation devices are included on these lines ONLY when:
A) The patient has cystic fibrosis, AND
1) There is documentation of frequent exacerbations requiring antibiotics, frequent hospitalization, OR rapidly declining lung function measured by spirometry, despite either:
a) having received chest physiotherapy and positive expiratory pressure therapy, OR
b) documentation that chest physiotherapy and positive expiratory pressure devices are not tolerated or not available (e.g., inability of a caregiver to perform chest physiotherapy); OR
B) The patient has non-cystic fibrosis bronchiectasis AND the four criteria below are met: 
1) The bronchiectasis is confirmed by computed tomography (CT) scan, AND
2) There is evidence of chronic lung infection, AND
3) The patient has experienced either:
a) daily productive cough for at least 6 continuous months, OR 
b) frequent (>2 times a year) exacerbations requiring antibiotic therapy, AND
4) The patient has received chest physiotherapy and positive expiratory pressure therapy OR chest physiotherapy and positive expiratory pressure devices are not tolerated, contraindicated, or not available (e.g., inability of a caregiver to perform chest physiotherapy); OR
C) The patient has neuromuscular disease resulting in chronic lung disease when there is evidence of chronic lung infection, despite either:
1) having received chest physiotherapy and positive expiratory pressure therapy, OR
2) documentation that chest physiotherapy and positive expiratory pressure devices are not tolerated, contraindicated, or not available (e.g., inability of a caregiver to perform chest physiotherapy).
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 231, LOW LEVEL LASER THERAPY
Lines 92,111,112,114,115,124,125,129,133,135,157,163,190,198,199,207,209,213,214,216,228,233,236,237,239,256,257,259-261,269,274,283-285,292,311-313,326,339,369,393-395,399,417,433,440,459,545,557
Low level laser therapy (HCPCS S8948; CDT **D9128 and D9129) is included on these lines only for prevention of oral mucositis for members undergoing cancer treatment associated with increased risk of oral mucositis, including chemotherapy, radiotherapy, and/or hematopoietic stem cell transplantation.
GUIDELINE NOTE 232, HIGH RISK FOOT CARE
Lines 164,482
Foot care by a medical professional, including paring and cutting of corns and calluses, debridement of nails, avulsion of nail plates, trimming of dystrophic nails, and biopsy of nails is included on Line 164 only when:
A) The patient is at high risk for complications from nail and foot problems due to a systemic condition that has resulted in severe circulatory insufficiency and/or areas of desensitization in the lower extremities; OR
B) The patient resides in a skilled nursing facility, rehabilitation facility, group home or similar institutional setting.
Evaluation for and treatment of tinea unguium (ICD-10-CM B35.1) including biopsy of nails, nail paring, and treatment with topical or oral antifungal medications is included on Line 164 only when:
A) The patient is in one of the two high risk groups identified above; AND 
B) There is clinical evidence of mycosis of the toenail; AND
C) The patient has documented marked limitation of ambulation, pain, and/or secondary bacterial infection resulting from the thickening and dystrophy of the infected toenail plate.
Otherwise, evaluation and treatment of tinea unguium is included on Line 482.
GUIDELINE NOTE 233, INSOMNIA
Line 201
Insomnia is included on this line for pairing with cognitive behavioral therapy (CBT).  Short term (up to 1 month per year) treatment with sedative-hypnotic medications is included on 
GUIDELINE NOTE 233, INSOMNIA (CONT'D)
this line only if the patient is currently in CBT or has failed to respond to recent CBT (in the past year).
Long-term (more than 1 month) treatment with sedative-hypnotic medications is not included on this line.
GUIDELINE NOTE 234, COMPLICATED HEMORRHOIDS
Lines 56,603
First through fourth degree hemorrhoids (ICD-10-CM K64.0, K64.1, K64.2, K64.3) are included on Line 56 only when
A) The patient has not responded to conservative management, including topical medications and dietary management; AND
B) There is recurrent hemorrhoidal bleeding resulting in anemia (hemoglobin less than 10 g/dL or hemoglobin less than 11 g/dL if use of iron is documented).
Otherwise, first through fourth degree hemorrhoids are included on Line 603. For first and second degree hemorrhoids only: treatment is limited to office-based procedures (for example, banding and sclerotherapy). Other surgical procedures are only included on Line 56 for third and fourth degree hemorrhoids.
ICD-10-CM K64.8 (Other hemorrhoids) is only included on Line 56 when representing strangulated hemorrhoids.
GUIDELINE NOTE 235, TREATMENT OF BENIGN PAROXYSMAL POSITIONING VERTIGO
Lines 290,501
Canalith repositioning maneuvers (CPT *95992) is included on Line 290 for treatment of benign paroxysmal positioning vertigo (BPPV) for up to 2 visits per year for education by a physical therapist or an otolaryngologist, with no requirement for conservative therapy or a waiting period prior to these visits.
Vestibular rehabilitation (CPT *97112 and HCPCS S9476) is included on Line 290 only when ALL of the following criteria are met:
A) The patient has benign paroxysmal positioning vertigo (BPPV); AND
B) The patient has tried and failed canalith repositioning maneuvers (CPT *95992) or has contraindications to canalith repositioning maneuvers; AND one or more of the following applies:
GUIDELINE NOTE 235, TREATMENT OF BENIGN PAROXYSMAL POSITIONING VERTIGO (CONT'D)
1) The patient is aged 65 or older; OR 
2) The patient is under age 65 and is at increased risk of falls; OR
3) The patient has symptoms (for example, vertigo and imbalance) for more than 6 weeks.
GUIDELINE NOTE 236, POSTERIOR TIBIAL NERVE STIMULATION
Line 324
Posterior tibial nerve stimulation (CPT *64566, 64590, HCPCS E0736) is included on Line 324 Line 324 only when ALL of the following criteria are met:
A) The patient has overactive bladder syndrome; AND 
B) The patient has had symptoms for at least 6 months and the condition has resulted in significant disability (the frequency and/or severity of symptoms are limiting the member's ability to participate in daily activities); AND
C) Documented failure or intolerance to pharmacotherapies and behavioral treatments (e.g., pelvic floor exercise, timed voids, and fluid management. 
Initial coverage is limited to 12 once-weekly treatments. If the member improves after 12 posterior tibial nerve stimulation treatments, continued monthly treatments are considered medically necessary as long as the member's symptoms remain improved. 
GUIDELINE NOTE 237, DEEP BRAIN STIMULATION
Lines 173,247,359
Deep brain stimulation for treatment of refractory epilepsy is included on Line 173 only when
A) The surgery is performed at a Level 4 epilepsy center, AND
B) The patient has failed two or more anti-seizure medications, AND
C) The patient is ineligible for resective surgery OR has failed vagus nerve stimulation or resective surgery.
Unilateral or bilateral deep brain stimulation (DBS) is included on Line 247 only for treatment of intractable tremors due to Parkinson's disease (PD) when all of the following conditions are met:
A) For thalamic ventrointermediate nucleus (VIM) DBS, patients must meet all of the following criteria:
GUIDELINE NOTE 237, DEEP BRAIN STIMULATION (CONT'D)
1) A diagnosis of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a tremor- dominant form
2) Marked disabling tremor of at least level 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy.
3) Willingness and ability to cooperate during conscious operative procedure, as well as during postsurgical evaluations, adjustments of medications and stimulator settings.
B) For subthalamic nucleus (STN) or globus pallidus interna (GPi) DBS, patients must meet all of the following criteria: 
1) Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia).
2) Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease Rating Scale (UPDRS) part III motor subscale.
3) L-dopa responsive with clearly defined "on" periods.
4) Persistent disabling Parkinson's symptoms or drug side effects (e.g., dyskinesias, motor fluctuations, or disabling "off" periods) despite optimal medical therapy. 
5) Willingness and ability to cooperate during conscious operative procedure, as well as during postsurgical evaluations, adjustments of medications and stimulator settings.
C) DBS is not included on Line 247 for PD patients with any of the following:
1) Non-idiopathic Parkinson's disease or "Parkinson's Plus" syndromes
2) Cognitive impairment, dementia or depression which would be worsened by or would interfere with the patient's ability to benefit from DBS
3) Current psychosis, alcohol abuse or other drug abuse
4) Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the movement disorder
5) Previous movement disorder surgery within the affected basal ganglion
6) Significant medical, surgical, neurologic or orthopedic co-morbidities contraindicating DBS.
Deep brain stimulation for treatment of essential tremor is included on Line 359 only when ALL of the following criteria are met:
GUIDELINE NOTE 237, DEEP BRAIN STIMULATION (CONT'D)
A) Diagnosis of essential tremor based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis of idiopathic Parkinson's disease (PD) (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a tremor-dominant form; AND
B) Marked disabling tremor of at least level 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy; AND
C) Willingness and ability to cooperate during conscious operative procedure, as well as during postsurgical evaluations, adjustments of medications and stimulator settings
Deep brain stimulation for treatment of dystonia is included on Line 359 only when ALL of the following criteria are met:
A) The patient is aged 7 years or older; AND
B) The patient has primary dystonia, including generalized and/or segmental dystonia, hemidystonia and cervical dystonia; AND
C) There has been inadequate improvement with medication and botulinum toxin denervation therapy; AND
D) Willingness and ability to cooperate during conscious operative procedure, as well as during postsurgical evaluations, adjustments of medications and stimulator settings
GUIDELINE NOTE 238, ULTRASOUND GUIDED PERCUTANEOUS TENOTOMY
Lines 356,373,399,414,415,480,492,494,515,526,587,591
Ultrasound guided percutaneous tenotomy is not included on any line on the prioritized list for treatment of any condition due to lack of evidence of effectiveness. There is no specific CPT or HCPCS code for this procedure.
GUIDELINE NOTE 239, INCIDENTAL APPENDECTOMY
Lines 47,100,157
Appendectomy (CPT *44950-44979) is included on these lines only for medically indicated appendectomy, defined as removal of the appendix for infection, inflammation, gangrene, obstruction, concern for malignancy, or other disease state, OR when the primary surgery will move the appendix from its normal anatomic location making future diagnosis of appendicitis difficult. Incidental appendectomy, defined as removal of the appendix during another procedure when no abnormality of the appendix is present, is not included on these lines.



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MULTISECTOR INTERVENTIONS
Note: The multisector interventions described below are provided as an aid in population health management and do not constitute Oregon Health Plan benefits.


MULTISECTOR INTERVENTION STATEMENT 1: TOBACCO PREVENTION AND CESSATION, INCLUDING DURING PREGNANCY
Benefit coverage for smoking cessation on Line 5 and in Guideline Note 4 TOBACCO DEPENDENCE, INCLUDING DURING PREGNANCY is intended to be offered with minimal barriers, in order to encourage utilization. To further prevent tobacco use and help people quit, additional evidence-based policy and programmatic interventions from a population perspective are available here:  
* Oregon Public Health Division's Health Promotion and Chronic Disease Prevention Section: Evidence-Based Strategies for Reducing Tobacco Use A Guide for CCOs https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/TOBACCOPREVENTION/Documents/evidence-based_strategies_reduce_tob_use_guide_cco.pdf 
* Community Preventive Services Task Force (supported by the CDC) - What Works: Tobacco Use http://www.thecommunityguide.org/about/What-Works-Tobacco-factsheet-and-insert.pdf 
The Community Preventive Services Task Force identified the following evidence-based strategies (available at https://thecommunityguide.org/pages/task-force-findings-tobacco.html):
MULTISECTOR INTERVENTION STATEMENT 1: TOBACCO PREVENTION AND CESSATION, INCLUDING DURING PREGNANCY (CONT'D)

To reduce the use of tobacco during pregnancy and improve associated outcomes, the evidence supports the following interventions:
MULTISECTOR INTERVENTION STATEMENT 1: TOBACCO PREVENTION AND CESSATION, INCLUDING DURING PREGNANCY (CONT'D)
* Financial incentives (incentives contingent upon laboratory tests confirming tobacco abstinence are the most effective)
* Smoke-free legislation 
* Tobacco excise taxes
MULTISECTOR INTERVENTION STATEMENT 2: PREVENTION OF EARLY CHILDHOOD CARIES
Evidence supports:	
* Community water fluoridation
* Fluoride varnish, including applied in a primary care setting
* Fluoride gel
* Oral fluoride supplementation
* Community-based programs that combine oral health education with supervised toothbrushing
Limited evidence supports:
* Motivational interviewing towards caregivers
Insufficient or conflicting evidence on:
* Anticipatory guidance/oral health education alone
* Encouragement of preventive dental visits
* Risk assessment
* Xylitol products
* Chlorhexidine
* Silver diamine fluoride
* School-based behavioral interventions
* Breastfeeding interventions
MULTISECTOR INTERVENTION STATEMENT 3: PREVENTION AND TREATMENT OF OBESITY
Limited evidence supports the following interventions:
MULTISECTOR INTERVENTION STATEMENT 3: PREVENTION AND TREATMENT OF OBESITY (CONT'D)
School and childcare settings
* School based interventions to reduce BMI (especially with physical activity focus)
* School nutrition policy and day care meal standards
* Family-based group education programs delivered in schools
* Obesity prevention interventions in childcare settings (nutrition education, healthy cooking classes for 2-6 year olds, physical activity and playful games)
Community level interventions
* Environmental interventions (social marketing, cafeteria signs, farmers markets, walking groups, etc.)
* Introduction of light rail
* Community-based group health education and counseling interventions, workplace education interventions
* Workplace and college interventions to improve physical activity
Multiple settings
* Interventions to reduce sedentary screen time (in some studies, also to increase physical activity and nutrition).
* Multicomponent individual mentored health promotion programs to prevent childhood obesity
* Parental support interventions for diet and physical activity (group education, mental health counseling)
Policy changes
* Sugar sweetened beverage taxes
* Elimination of tax subsidy for advertising unhealthy food to children
This Multisector Interventions statement is based on the work of the HERC Obesity Task Force and the full summary of the evidence report is available at https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx 
MULTISECTOR INTERVENTION STATEMENT 4: COMMUNITY HEALTH WORKERS
To improve beneficial outcomes in patients with chronic conditions, the preponderance of evidence supports that community health workers (CHWs) serving as a part of an integrated care team appear to improve outcomes in:
* Children with asthma with preventable emergency department visits
* Adults with uncontrolled diabetes or uncontrolled hypertension
This evidence includes an emphasis on minority and low-income populations.
Characteristics of effective interventions include:
* Higher intensity interventions including longer duration
* Targeting populations with more severe chronic disease at baseline
Community health workers may be effective for patients with other conditions, however, limited was found for any other chronic condition.
This Multisector Interventions statement is based on a HERC evidence review, Community Health Workers for Patients with Chronic Disease https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx.
MULTISECTOR INTERVENTION STATEMENT 5: MULTICOMPONENT INTERVENTIONS TO IMPROVE SCREENING OUTCOMES OR ATTENDANCE FOR BREAST, CERVICAL, OR COLORECTAL CANCER
To improve attendance at cancer screening for breast, cervical, and colorectal cancer, the evidence supports the following interventions across cancer types (ordered roughly according to effect size):
Across Cancer Types
Effective interventions
   General population
* Combined approach including three interventions group (with objectives to increase community demand, community access, and provider delivery) (CPSTF, 2016)
MULTISECTOR INTERVENTION STATEMENT 5: MULTICOMPONENT INTERVENTIONS TO IMPROVE SCREENING OUTCOMES OR ATTENDANCE FOR BREAST, CERVICAL, OR COLORECTAL CANCER (CONT'D)
* Patient navigation (Ali-Faisal et al, 2017)
* Combined approach including two interventions (with objectives to increase community demand and access) (CPSTF, 2016)
o Increasing access is more effective than increasing demand
* Community health workers (Bellhouse et al, 2018)
* Narrative interventions (i.e. story-based; breast cancer and colorectal cancer) (Perrier et al, 2017)
* Clinician communication interventions (breast cancer and colorectal cancer) (Peterson et al, 2016)
o Practice-facilitation workflow/communication skills training (breast cancer and colorectal cancer) (Peterson et al, 2016)
   Subpopulations
* Limited English proficiency
o Patient navigation (Genoff et al, 2016)
* Vulnerable populations
o Community health workers (Kim et al, 2016)
* Hispanic/Latina populations
o Educational interventions (promotora-delivered, one-on-one, group, combined, church or community-based settings) (Luque et al, 2018)
Interventions with unclear effectiveness
* Special events like health fairs, parties, special day (breast cancer, colorectal cancer and cervical cancer screening) (Escoffery et al, 2014)
* Clinician performance incentives (Mauro et al, 2019)
Breast Cancer Screening
Effective interventions
MULTISECTOR INTERVENTION STATEMENT 5: MULTICOMPONENT INTERVENTIONS TO IMPROVE SCREENING OUTCOMES OR ATTENDANCE FOR BREAST, CERVICAL, OR COLORECTAL CANCER (CONT'D)
   General population
* Two or more intervention approaches to increase community demand, community access and provider delivery (CPSTF, 2016)
* Two or more intervention approaches to reduce different structural barriers (CPSTF, 2016)
   Subpopulations
* Multicomponent interventions to increase community demand or access in
o African American populations (Copeland et al, 2018)
o Rural areas (Rodriguez-Gomez et al, 2020)
* Multicomponent interventions that includes increasing provider delivery of screening services in rural areas (Rodriguez-Gomez et al, 2020)
* Individual-tailored educational interventions (provided by lay health workers) in American Indian/Alaska Native populations (Jerome D'Emilia et al, 2019)
Interventions with unclear effectiveness
* Health promotion programs (community-, home- or telephone-based) in ethnic minority women (Chan et al, 2015)
* Culturally tailored interventions (videos, individually tailored telephone counseling) in Chinese American women (Zhang et al, 2020)
Ineffective interventions
* Client reminders (calendar with health reminders) in American Indian/Alaska Native populations (Jerome D'Emilia et al, 2019)
* Small media in rural areas (Rodriguez-Gomez et al, 2020)
* One-on-one education in rural areas (Rodriguez-Gomez et al, 2020)
Cervical Cancer Screening 
Effective interventions
MULTISECTOR INTERVENTION STATEMENT 5: MULTICOMPONENT INTERVENTIONS TO IMPROVE SCREENING OUTCOMES OR ATTENDANCE FOR BREAST, CERVICAL, OR COLORECTAL CANCER (CONT'D)
   General population
* Multicomponent interventions (two or more out of three categories) to increase community demand, access, or provider delivery (CPSTF, 2016)
* Two or more interventional approaches to reduce different structural barriers (CPSTF, 2016)
   Subpopulations
* Rural populations (Rodriguez-Gomez et al, 2020)
o Small media alone
o Combination of small media, one-on-one education and client reminders 
o Combination of mass media, group education, and reducing structural barriers (e.g. HPV self-collection kit)
* Lower socioeconomic status populations
o Client reminders (e.g. invitation) (Rees et al, 2018)
o Lay health advisors (Rees et al, 2018)
o Clinic-based strategies (Rees et al, 2018)
* Hispanic/Latina populations (Mann et al, 2015)
o Lay health advisors
o Clinic-based strategies
o Church partnerships
Interventions with unclear effectiveness
* Health promotion programs alone in ethnic minority women (Chan et al, 2015)
Ineffective interventions
   General population
* Provider assessment and feedback (CPSTF, 2016)
   Subpopulations
* Rural areas (Rodriguez-Gomez et al, 2020)
MULTISECTOR INTERVENTION STATEMENT 5: MULTICOMPONENT INTERVENTIONS TO IMPROVE SCREENING OUTCOMES OR ATTENDANCE FOR BREAST, CERVICAL, OR COLORECTAL CANCER (CONT'D)
o Combination of group education and small media 
o Client reminders (e.g. invitation)
o Small media (e.g. mailed video)
Colorectal Cancer Screening
Effective interventions
   General population
* Multicomponent interventions (=2 out of 3 categories) to increase community demand, access, or provider delivery (CPSTF, 2016; Dougherty et al, 2019)
* Two or more out of three intervention approaches to reduce different structural barriers (CPSTF, 2016)
* Distribution of fecal blood tests (in clinic or mailed outreach) (Dougherty et al, 2019; Issaka et al, 2019; Jager et al, 2019)
* Patient navigation (Dougherty et al, 2019)
* Multicomponent interventions (two or more out of three categories) to increase community demand, access, or provider delivery (CPSTF, 2016)
* Interventions focused on increasing community access
* Tailored communication interventions compared to control (Issaka et al, 2019)
* Clinician-directed interventions (Dougherty et al, 2019)
* Combination of FIT and influenza vaccination clinic (Issaka et al, 2019)
* Patient decision aids (Volk et al, 2016)
* Educational interventions (Dougherty et al, 2019; Issaka et al, 2019)
* Patient reminders (Dougherty et al, 2019)
   Subpopulations
* Multicomponent interventions effective at increasing screening adherence in rural areas (Rodriguez-Gomez et al, 2020)
MULTISECTOR INTERVENTION STATEMENT 5: MULTICOMPONENT INTERVENTIONS TO IMPROVE SCREENING OUTCOMES OR ATTENDANCE FOR BREAST, CERVICAL, OR COLORECTAL CANCER (CONT'D)
* Multicomponent interventions effective at increasing fecal testing in low-income and rural populations (Davis et al, 2018)
* First-degree relatives of individuals with colorectal cancer
o Tailored communication interventions (Bai et al, 2020)
* Rural and low-income populations (Davis et al, 2018)
o Multicomponent interventions to increase community demand, community access, and/or provider delivery
* Federally qualified health centers (Domingo et al, 2017)
o Patient navigation
* Asian Americans (Kim et al, 2020)
o Culturally responsive interventions
Interventions with unclear effectiveness
* Interventions to increase community demand (Young et al, 2019)
* Tailored communication interventions based on family history and personal factors compared to mailed FIT kits (Issaka et al, 2019)
Ineffective interventions
   General population
* Patient financial incentives (Dougherty et al, 2019)
* Small media (low literacy picture book, video mailed with FIT kit) (Issaka et al, 2019)
   Subpopulations
* Rural areas (Rodriguez-Gomez, 2020)
o Client reminders (e.g., telephone)
o Clinician reminders (e.g., chart reminder)
o Demonstrating how to use FIT kit
This Multisector Interventions statement is based on a HERC evidence review, Multicomponent Interventions to Improve Screening Outcomes or Attendance for Breast, Cervical, or Colorectal Cancer https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx.