| Rosacea Procedures | 0482 · Effective Jun 15, 2025 · Commercial | 12 | Original policy ↗ |
| Sacral Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation | 0404 · Effective Nov 15, 2025 · Commercial | 14 | Original policy ↗ |
| Scar Revision | 0328 · Effective Jun 15, 2026 · Commercial | 45 | Original policy ↗ |
| Scrotal Ultrasound | 0548 · Effective Jul 15, 2026 · Commercial | 1 | Original policy ↗ |
| Seat Lift Mechanisms, Patient Lifts and Standing Devices | 0343 · Effective Jun 14, 2026 · Commercial | 15 | Original policy ↗ |
| Sensory and Auditory Integration Therapy - Facilitated Communication | CPG149 · Effective Jun 15, 2026 · Commercial | 3 | Original policy ↗ |
| Serum Folate and Red Blood Cell Folate Testing | 0567 · Effective Dec 15, 2025 · Commercial | 2 | Original policy ↗ |
| Site of Care: High-tech Radiology - (0550) | 0550 · Commercial | — | Original policy ↗ |
| Site of Care: Outpatient Hospital Setting for Physical and Occupational Therapy | 0600 · Effective Aug 15, 2026 · Commercial | — | Original policy ↗ |
| Specialty Medical Injectables with Reimbursement Restriction | Commercial | 88 | Original policy ↗ |
| Speech Generating Devices | 0049 · Effective Jan 15, 2026 · Commercial | 4 | Original policy ↗ |
| Spinal Ultrasound | CPG038 · Effective Sep 15, 2026 · Commercial | 3 | Original policy ↗ |
| Staff-Assisted Home Hemodialysis | 0229 · Effective Nov 15, 2025 · Commercial | 1 | Original policy ↗ |
| Stem Cell Therapy for Orthopaedic Applications | 0552 · Effective Dec 15, 2025 · Commercial | 7 | Original policy ↗ |
| Stem Cell Transplantation: Blood Cancers | 0533 · Effective Aug 15, 2026 · Commercial | 20 | Original policy ↗ |
| Stem Cell Transplantation: Non-Cancer Disorders | 0535 · Effective Jan 15, 2026 · Commercial | 19 | Original policy ↗ |
| Stem Cell Transplantation: Solid Tumors | 0534 · Effective Jan 15, 2026 · Commercial | 19 | Original policy ↗ |
| Strapping and Taping | CPG143 · Effective May 15, 2026 · Commercial | 13 | Original policy ↗ |
| Subtalar Joint Implantation (Subtalar Arthroereisis) | 0486 · Effective Oct 15, 2025 · Commercial | 4 | Original policy ↗ |
| Surgical Treatment of Chest Wall Deformities | 0309 · Effective Apr 15, 2026 · Commercial | 9 | Original policy ↗ |
| Surgical Treatments for Obstructive Sleep Apnea | 0158 · Effective Jun 15, 2026 · Commercial | 28 | Original policy ↗ |
| Surgical Treatments for Obstructive Sleep Apnea | 0158 · Effective Dec 15, 2026 · Commercial | 26 | Original policy ↗ |
| Temporomandibular Joint (TMJ) Disorder Surgery | 0156 · Effective Dec 15, 2025 · Commercial | 7 | Original policy ↗ |
| Thymus Tissue Transplantation | 0561 · Effective Aug 15, 2026 · Commercial | 5 | Original policy ↗ |
| Tilt Table Testing | 0270 · Effective Dec 15, 2025 · Commercial | 1 | Original policy ↗ |
| Tissue-Engineered Skin Substitutes | 0068 · Effective Oct 1, 2026 · Commercial | 172 | Original policy ↗ |
| Total Ankle Arthroplasty/Replacement | 0285 · Effective Mar 15, 2026 · Commercial | 4 | Original policy ↗ |
| Transcatheter Closure of Cardiovascular Defects | 0011 · Effective Nov 15, 2025 · Commercial | 5 | Original policy ↗ |
| Transcatheter Heart Valve Procedures | 0501 · Effective Dec 15, 2025 · Commercial | 13 | Original policy ↗ |
| Transcranial Magnetic Stimulation | EN0383 · Effective Mar 15, 2026 · Commercial | 9 | Original policy ↗ |
| Transition of Care Service Requests For New Customers | UM-35 · Effective Sep 1, 2000 · Commercial | — | Original policy ↗ |
| Transition to or from a Group Benefit Plan Serviced by Behavioral Health - (HM-CLN-037) | HM-CLN-037 · Commercial | — | Original policy ↗ |
| Transthoracic Echocardiography in Adults | 0510 · Effective Sep 15, 2026 · Commercial | 15 | Original policy ↗ |
| Transthoracic Echocardiography in Children | 0523 · Effective Sep 15, 2026 · Commercial | 15 | Original policy ↗ |
| Transvaginal Ultrasound, Non-Obstetrical | 0398 · Effective Mar 15, 2026 · Commercial | 1 | Original policy ↗ |
| Treatment of Cutaneous and Vascular Lesions | 0313 · Effective May 15, 2026 · Commercial | 3 | Original policy ↗ |
| Treatment of Cutaneous and Vascular Lesions | 0313 · Effective Oct 15, 2026 · Commercial | 4 | Original policy ↗ |
| Tumor In Vitro Chemosensitivity and Chemoresistance Assays | 0203 · Effective Apr 15, 2026 · Commercial | 6 | Original policy ↗ |
| Ultrasound Guidance for Trigger Point Injections | 0139 · Effective Jul 15, 2026 · Commercial | 1 | Original policy ↗ |
| Ultrasound in Pregnancy (including 3D, 4D and 5D Ultrasound) | 0142 · Effective Aug 15, 2026 · Commercial | 4 | Original policy ↗ |
| Vagus Nerve Stimulation (VNS) | 0350 · Effective Feb 15, 2026 · Commercial | 18 | Original policy ↗ |
| Vascularized Composite Allograft (VCA) Transplantation | 0560 · Effective Jan 15, 2026 · Commercial | 5 | Original policy ↗ |
| Ventricular Assist Devices (VADs), Percutaneous Cardiac Support Systems and Total Artificial Heart | 0054 · Effective Dec 15, 2025 · Commercial | 14 | Original policy ↗ |
| Vitamin D Testing | 0526 · Effective Sep 15, 2026 · Commercial | 3 | Original policy ↗ |
| Wheelchairs/Power Operated Vehicles | A024 · Effective Jun 14, 2026 · Commercial | 357 | Original policy ↗ |
| Wide-Area Transepithelial Tissue Sampling with Computer-Assisted 3D Analysis (WATS3D) | 0578 · Effective Dec 15, 2025 · Commercial | 5 | Original policy ↗ |
