| BCBS South Dakota Medical Policies | Dopamine Transporter Single-Photon Emission Computer Tomography of the Brain | 2023-12-01 |
| BCBS South Dakota Medical Policies | Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus | 2023-12-01 |
| BCBS South Dakota Medical Policies | Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease | 2023-12-01 |
| BCBS South Dakota Medical Policies | Minimally-Invasive Surgical Treatments for Scoliosis | 2023-12-01 |
| BCBS South Dakota Medical Policies | Miscellaneous Investigational Treatments for Reflux Disease | 2023-12-01 |
| BCBS South Dakota Medical Policies | Peroral Endoscopic Myotomy (POEM) Procedures | 2023-12-01 |
| BCBS South Dakota Medical Policies | Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease | 2023-12-01 |
| HealthPartners | Upper airway/hypoglossal nerve stimulation therapy | 2023-12-01 |
| Ambetter Health Texas Superior Medicaid Clinical | Leveling of Emergency Room Services - Facility (CC.PP.064) | 2023-12-01 |
| Ambetter Health Texas Superior Medicaid Clinical | Not Medically Necessary Inpatient Professional Services (CC.PP.060) | 2023-12-01 |