medicare advantage - zipari

Medicare Advantage

On behalf of Premera Blue Cross Advantasure provides prior authorization services Prior authorization is not a guarantee of

payment Benefits are based on eligibility at the time of service and are subject to applicable contract terms

Code Description Effective Date

Providers Who to Contact for Review

104 Anesthesia for electroconvulsive therapy Optum Behavioral Health

Optum Provider Portal 844-884-1855

00731 Anesthesia for upper gastrointestinal endoscopic procedures endoscope introduced proximal to duodenum not otherwise specified

10-16-2018 Premera Blue Cross Provider Portal 855-339-8127

00732 Anesthesia for upper gastrointestinal endoscopic procedures endoscope introduced

proximal to duodenum endoscopic retrograde cholangiopancreatography (ERCP)

10-16-2018 Premera Blue Cross

Provider Portal 855-339-8127

00811 Anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to

duodenum not otherwise specified



00812 Anesthesia for lower intestinal endoscopic 10-16-2018 Premera Blue Cross Provider Portal 855-339-8127

00813 Anesthesia for lower intestinal endoscopic 10-16-2018 Premera Blue Cross Provider Portal

855-339-8127

11920 TattooColor Defect to 60 Sq Cm 05-01-2018 Premera Blue Cross


Y0134_PriorAuthList_C FVNR 1019

We display one prior authorization list for all Premera Medicare Advantage plans

bull Providers We recommend you review this list before you submit your requests

bull CPT codes with an asterisk () may be processed and reviewed for prior authorization by either Optum Behavioral Health or Advantasure UM based on the members diagnosis

bull All Part B medications are now grouped together at the end of the prior authorization list bull CPT codes with a plus symbol (dagger) are for drugs that have prior authorization overlap with Part D formulary

bull CPT codes with a diamond symbol () are for Part B drugs that require Step Therapy

Code Description Effective

Date

Providers Who to Contact for

Review

11922 TattooColor Defect Ea Add 20 Sq Cm 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15002 Surgical Preparation or Creation of Recipient Site TAL 1st 100 Sq Cm or 1 of Body Area of Infants and Children


Provider Portal

855-339-8127

15003 Surgical Preparation or Creation of Recipient Site TAL Ea Addl 100 Sq Cm or Ea Addl 1 of Body Area InfantChild

05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15004 Surgical Preparation or Creation of Recipient Site FSEMNEOGHFD 1st 100 Sq Cm

or 1 of Body Area InfantChild


Provider Portal

855-339-8127

15005 Surg Preparation or Creation of Recipient Site FSEMNEOGHFD Ea Addl 100 Sq

Cm or 1 Of Body Area InfantChild


855-339-8127

15271 Skin Subst Graft To Trunk Arms Legs Area Up To 100 Sq Cm First 25 Sq Cm Or Less Wound Surface Area


15272 Skin Subst Graft To Trunk Arms Legs Area Up To 100 Sq Cm Ea Additional 25 Sq Cm Wound Service Area Or Part Thereof



15273 Skin Subst Graft To Trunk Arms Legs Area gt= 100 Sq Cm 1St 100 Sq Cm Or 1 Of Body

Area Of Infants And Children


Provider Portal

855-339-8127

15274 Skin Subst Graft To Trunk Arms Legs Area gt= 100 Sq Cm Ea Addl 100 Sq Cm Or Ea Adl

1 Of Body Area Of InfampChildren


855-339-8127

15275 Skin Subst Graft To FSEMNEOGHFD Area Up To 100 Sq Cm 1St 25 Sq Cm Or Less Wound Surface Area




855-339-8127

15277 Skin Subst Graft To FSEMNEOGHFD Area gt= 100 Sq Cm 1St 100 Sq Cm Or 1

Of Body Area Of Infants And Children


855-339-8127

15278 Skin Subst Graft To FSEMNEOGHFD Area gt= 100 Sq Cm Ea Addl 100 Sq Cm Or 1 Of Body Area Of Infants And Children




Date


Review

15820 Blepharoplasty Lower Eyelids 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15821 Blepharoplasty W Extensive Fat Pads 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

15822 Blepharoplasty Upper Eyelid 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

15823 Rhytidectomy W Excess Skin On Lids 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15830 Excision Excessive Skin and Subcutaneous Tissue (Includes Lipectomy) Abdomen Infraumbilical Panniculectomy


Provider Portal

855-339-8127

15832 Exc Excess Skin Subq Tiss Thigh 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15833 Exc Excess Skin Leg 05-01-2018 Premera Blue Cross


15834 Exc Excess Skin Subq Tiss Hip 05-01-2018 Premera Blue Cross


15835 Exc Excess Skin Buttock 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15836 Exc Excess Skin Subq Tiss Arm 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15837 Exc Excess Skin Forearm 05-01-2018 Premera Blue Cross


15838 Exc Excess Skin Subq Tiss Fat Pad 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15839 Exc Excess Skin Other Area 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

15847 Excision Excessive Skin and Subcutaneous Tissue (Includes Lipectomy) Abdomen 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

17106 Dest Cut Vasc Proliferative Les to 10 Sq 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

17107 Dest Cut Vasc Prolif Les 10-50 Sq cm 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

17108 Dest Cut Vasc Proliferative Les Over 50 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19296 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into

the breast for interstitial radioelement application following partial mastectomy includes

image guidance

01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776



image guidance


AIM Provider Portal

866-666-0776

19298 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and

button type) into the breast for interstitial radioelement application following partial

mastectomy includes image guidance


AIM Provider Portal

866-666-0776

19300 Mastectomy for gynecomastia 05-01-2018 Premera Blue Cross


19316 Mastopexy 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

19318 Mammoplasty Reduction 05-01-2018 Premera Blue Cross


19324 Mammaplasty Augment WoProsthetic Implant 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19325 Mammoplasty Augmentation W Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

19328 Removal of Intact Mammary Implant 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

19330 Removal Mammary Implant Unilateral 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19340 Insert Breast Prosthesis Immediate 05-01-2018 Premera Blue Cross


19342 Delay Insert Prosthesis MastRecons 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19350 Reconstruct NippleAreolar Unil 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

19355 Correction Inverted Nipple(S) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19357 Breast Recon WTiss Expander Inc Expansion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

19361 Breast Recon Latissimus Dorsi Flap WWo 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19364 Breast Reconstruction WFree Flap 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

19366 Reconstruction Breast Other Method 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19367 Breast Reconstn W Trans Rectus Abdominis Musc Flap (Tram) SGL Pedicle 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

19368 Breast Reconstn Trans Rect Abd Musc Flap (Tram) SGL Ped Mic Anast 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19369 Breast Reconstn W Trans Rectus Abdominis Musc Flap (Tram) DBL Pedicle 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

19370 Open Periprosthetic Capsulotomy Breast 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19371 Capsulectomy Periprosthetic Breast 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

19380 Revision Reconstructed Breast 05-01-2018 Premera Blue Cross


19396 Preparation Moulage Breast Implant 05-01-2018 Premera Blue Cross


20555 Placement of needles or catheters into muscle andor soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure)

01-01-2019 AIM Specialty Health AIM Provider Portal

866-666-0776

20930 Allograft for Spine Surgery Morselized 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

20937 Autograft for Spine Surgery Morselized 05-01-2018 Premera Blue Cross


20974 Stimulate Bone Electric Noninvasive 05-01-2018 Premera Blue Cross


20975 Electrical Stim Aid Bone Heal Invasive 05-01-2018 Premera Blue Cross


20979 Low intensity ultrasound stimulation to aid bone healing noninvasive (nonoperative) 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21070 Coronoidectomy Unilateral 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21077 Impression and Custom Preparation Orbital Prosthesis 05-01-2018 Premera Blue Cross


21081 ImpressPrep Mandibular Resection 05-01-2018 Premera Blue Cross



Date


Review

21082 Impress Custom Prep Palatal Augmentation 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21083 ImpressPrep Palatal Lift Prosth 05-01-2018 Premera Blue Cross


21085 ImpressPrep Oral Surgical Splint 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21086 Impress Custom Prep Auricular Prosth 05-01-2018 Premera Blue Cross


21087 ImpressPrep Nasal Prosth 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21088 Impress Custom Prep Facial Prosth 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21110 Apply Interdental Fixation Other 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21121 Genioplasty Sliding Osteotomy Single Pie 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21122 Genioplasty Slide Osteotomy 2+ 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

21123 Genioplasty Sliding Augmentation WBone 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21141 Reconstruction Midface Single Piece 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

21142 Reconstruction Midface Two Pieces 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21143 Reconstruction Midface Three or More Pieces 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

21145 Recon Midface Lefort I Single Graft 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21146 Recon Midface Lefort I 2 Piece WBone Gr 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21147 Recon Midface Lefort I 3+ Pcs Graft 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21150 Recon Midface Lefort II Anterior Intrusi 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21151 Recon Midface Lefort II WBone Grft 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21154 Recon Midface Lefort III wo Lefort I 05-01-2018 Premera Blue Cross


21155 Recon Midface Lefort III w Lefort I 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21159 Recon Midface Lefort III wGraft wo Lefort l 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

21160 Recon Midface Lefort III wGrft wLefort l 05-01-2018 Premera Blue Cross


21196 Recon Mand Ramus Sag Split WRigid Rix 05-01-2018 Premera Blue Cross


21198 Osteotomy Mandible Segmental 05-01-2018 Premera Blue Cross


21199 Osteotomy Mandible Segmental with Genioglossus Advancement 05-01-2018 Premera Blue Cross


21206 Osteotomy Maxilla Segmental 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

21208 Osteoplasty Facial Bone Augment 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21209 Osteoplasty Facial Reduction 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21210 Graft Bone Nasal Maxilla Malar Area 05-01-2018 Premera Blue Cross


21215 Graft Bone Mandible 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21230 Graft Rib Cart to Face Chin Nose Ear 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21244 Reconstruct Mandible W Bone Plate 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21245 Recon Mand Max Subperiosteal Part 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21246 Repair Jaw W Subperiost Implnt Tot 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21247 Recon Mand Condyle Bone Cart Auto 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21248 Recon Mandible Maxilla Endosteal Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

21249 Repair Jaw W Endosteal Implnt Tot 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21256 Recon Orbit W OsteotomiesBone Grft 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21260 Periorbital Osteotomy WGraft Extracrani 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

21261 Rep Orbit Hypertelorism Combin Appr 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21263 Periorbital Osteotomy WGraft Forehead A 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

21267 Reposition Orbit Unil Extracranial 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21268 Orbit Reposition Unilat WGraft IntraEx 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21275 2ndary Revision Orbitocraniofacial Recon 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21685 Hyoid Myotomy and Suspension 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21740 Recon Rep Pectus ExcavaCarinatum 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

21742 Reconstructive Repair of Pectus Excavatum or Carinatum Minimally Invasive Approach

(Nuss Procedure) Wo Thoracoscopy


Provider Portal

855-339-8127


(Nuss Procedure) w Thoracoscopy


22100 Resect Vertebra Part Cervical 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22101 Part Resec Vertebral Spinous Process Tho 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

22102 Resect Vertebra Part Lumbar 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

22103 Partial Excision of Posterior Vertebral Component for each additional 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22110 Exc Vertebra Part Cervical 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

22112 Exc Vertebra Part Thoracic 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

22114 Exc Vertebra Part Lumbar 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

22116 Partial Excision of Vertebral Body for each additional Vertebral Segment 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22510 Percutaneous vertebroplasty (bone biopsy included when performed) 1 vertebral body

unilateral or bilateral injection inclusive of all imaging guidance cervicothoracic




unilateral or bilateral injection inclusive of all imaging guidance lumbosacral




unilateral or bilateral injection inclusive of all imaging guidance each additional cerv



22513 Percutaneous vertebral augmentation including cavity creation (fracture reduction and

bone biopsy included when performed) using mechanical device (eg kyphoplasty) 1 verteb







22515 Percutaneous vertebral augmentation including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg kyphoplasty) 1 verteb



22532 Arthrodesis Lateral Extracavitary Technique Including Minimal Diskectomy To Prepare Interspace Thoracic



22533 Arthrodesis Lateral Extracavitary Technique Including Minimal Diskectomy To Prepare Interspace Lumbar




Date


Review

22534 Arthrodesis Lateral Extracavitary Technique Including Minimal Diskectomy Thoracic or

Lumbar Each Additional Segment


855-339-8127

22548 ArthrodesTxsExtraoral Clivus -C1- 2 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22551 Arthrodesis Anterior Interbody Cervical Below C2 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22552 Arthrodesis anterior interbody including disc space preparation discectomy

osteophytectomy and decompression of spinal cord andor nerve roots cervical below C2 each add



22554 Arthrodesis Ant Interbody-C2 Below 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22556 Arthrodesis Ant Interbody- Thoracic 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22558 ArthrodInterbdy Techlumbar Allog 05-01-2018 Premera Blue Cross


22590 Arthrodesis Post-Craniocervical 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22595 ArthrodesisPosterTech Atlas- AxisC1-C2 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

22600 Fusion Cervical Post lt C1 05-01-2018 Premera Blue Cross


22610 Arthrodesis Post-Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

22612 ArthrodesisPosterior Posterolateral Tec 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

22614 Arthrodesis each additional Vertebral Segment 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22630 Arthrodesis Post Interbody- Lumbar 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22632 Arthrodesis each additional Interspace 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

22633 Arthrodesis Combined Post Or Postlatl Tech W Post Interbdy TechIncl Lamectmy

ampDiscectomySgl Interspace amp Segmt Lumb


855-339-8127

22634 Arthrodesis Combind Post Or Postlatl Tech W Post Interbdy TechIncl Lamectmy

ampDiscectomySgl Interspce amp Segmt Ea Addl


855-339-8127

22840 PosInstrumnteg Harringtn Rod 05-01-2018 Premera Blue Cross


22841 Internal Spinal Fixation by Wiring of Spinous Processes 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

22842 Instrumentat Post W Segment Wiring 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22843 Posterior Segmental Instrumentation 7 To 12 Vertebral Segments 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

22844 Posterior Segmental Instrumentation 13 or More Vertebral Segments 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22845 Anterior Instrumentation 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

22846 Anterior Instrumentation 4 To 7 Vertebral Segments 05-01-2018 Premera Blue Cross


22847 Anterior Instrumentation 8 or More Vertebral Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

22853 Insertion of interbody biomechanical device(s) (eg synthetic cage mesh) with integral anterior instrumentation for device anchoring (eg screws flanges) when performed to intervertebral disc space in conjunction with interbody arthrodesis each interspace (List separately in addition to code for primary procedure)


855-339-8127

22854 Insertion of intervertebral biomechanical device(s) (eg synthetic cage mesh) with integral

anterior instrumentation for device anchoring (eg screws flanges) when performed to

vertebral corpectomy(ies) (vertebral body resection partial or complete) defect in

conjunction with interbody arthrodesis each contiguous defect (List separately in


Provider Portal

855-339-8127

22856 Total Disc Arthroplasty Anterior Approach Including Discectomy with End Plate

Preparation Single Interspace Cervical


Provider Portal

855-339-8127

22859 Insertion of intervertebral biomechanical device(s) (eg synthetic cage mesh

methylmethacrylate) to intervertebral disc space or vertebral body defect without

interbody arthrodesis each contiguous defect (List separately in addition to code for

primary procedure)


Provider Portal

855-339-8127

22861 Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc) Anterior

Approach Single Interspace Cerv


855-339-8127

22864 Removal of Total Disc Arthroplasty (Artificial Disc) Anterior Approach Single Interspace Cervical



23470 Arthroplasty glenohumeral joint hemiarthroplasty 05-01-2018 Premera Blue Cross


23472 Arthroplasty total shoulder 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

27096 Injection procedure for sacroiliac joint anestheticsteroid with image guidance

(fluoroscopy or CT) including arthrography when performed


AIM Provider Portal

866-666-0776

27130 Arthroplasty acetabular proximal femoral prosthetic replacement (total Hip

arthroplasty)with or without autograft or allograft


Provider Portal

855-339-8127

27132 Conversion of previous hip surgery to total hip arthroplasty with or without autograft or allograft


855-339-8127

27279 Arthrodesis sacroiliac joint percutaneous or minimally invasive (indirect visualization)

with image guidance includes obtaining bone graft when performed and placement of

transfixing device


855-339-8127


Date


Review

27280 Arthrodesis Sacroiliac Joint 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

27332 Arthrotomy with excision of semilunar cartilage (meniscectomy) knee medial OR lateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

27333 Exc Semilunar Cartilage Med + Lat 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

27412 Autologous Chondrocyte Implantation Knee 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

27415 Rep Ligaments Knee+pes Anserin Tran 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

27416 Osteochondral autograft(s) knee open (eg mosaicplasty) (includes harvesting of

autograft[s]) Advancement Pes Anserinus


855-339-8127

27446 Arthroplasty knee condyle and plateau medial or lateral compartment 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

27447 Arthroplasty knee medical and lateral compartments with or without patella resurfacing(total knee arthroplasty)


855-339-8127

27700 Arthroplasty Ankle 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

27702 Arthroplasty Ankle with Implant (Total) 05-01-2018 Premera Blue Cross


27703 Arthroplasty Ankle Second Reconstr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

27704 Removal of Ankle Implant 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

28291 Hallux rigidus correction with cheilectomy debridement and capsular release of the first

metatarsophalangeal joint with implant 05-01-2018 Premera Blue Cross



Date


Review

29861 Arthroscopy Hip Surgical With Removal Of Loose Body Or Foreign Body 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

29862 Arthroscopy Hip Surg W Chondroplsty Arthroplsty amp Labrum Resectn 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

29863 Arthroscopy Hip Surgical With Synovectomy 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

29866 Arthroscopy Knee Surgical Osteochondral Autograft(S) (Eg Mosaicplasty) (Includes Harvesting Of The Autograft)



29867 Arthroscopy Knee Surgical Osteochondral Allograft (Eg Mosaicplasty) 05-01-2018 Premera Blue Cross


29868 Arthroscopy Knee Surgical Meniscal Transplantation (Includes Arthrotomy For Meniscal

Insertion) Medial Or Lateral


855-339-8127

29879 Arthroscopy Knee 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

29886 ArthroscKneeSurgdrill-Intact OstDiss 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

30400 Rhinoplasty Primary Partial 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

30410 Rhinoplasty Prim complete Extern Parts 05-01-2018 Premera Blue Cross


30420 Rhinoplasty Primary Maj Septal Rep 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

30430 Rhinoplasty2ndary minor Revision 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

30435 Rhinoplasty 2ndary intermediate revision (bony work with osteotomies) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

30450 Rhinoplasty 2ndary major revision (nasal tip work and osteotomies) 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

30460 Rhinoplasty for nasal deformity 2ndary to congenital cleft lip andor palate incl columellar lengthening tip only


855-339-8127

30462 Rhinoplasty for nasal deformity 2ndary to congenital cleft lip andor palate incl columellar

lengthening tip septum osteotomies



31295 Nasalsinus endoscopy surgical with dilation of maxillary sinus ostium (eg balloon dilation) transnasal or via canine fossa


855-339-8127

31296 Nasalsinus endoscopy surgical with dilation of frontal sinus ostium (eg balloon dilation) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

31297 Nasalsinus endoscopy surgical with dilation of sphenoid sinus ostium (eg Balloon dilation)


855-339-8127

31298 Nasalsinus endoscopy surgical with dilation of frontal and sphenoid sinus ostia (eg balloon dilation)


Provider Portal

855-339-8127

31643 Bronchoscopy rigid or flexible including fluoroscopic guidance when performed with

placement of catheter(s) for intracavitary radioelement application


AIM Provider Portal

866-666-0776

31660 Bronchoscopy rigid or flexible including fluoroscopic guidance when performed with bronchial thermoplasty 1 lobe


855-339-8127

31661 Bronchoscopy rigid or flexible including fluoroscopic guidance when performed with bronchial

thermoplasty 2 or more lobes 04-01-2020 Premera Blue Cross

Provider Portal

855-339-8127

32664 Thoracoscopy Surgical with Thoracic Sympathectomy 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

32850 Donor Pneumonectomy(ies) W Prep and Maintenance of Allograft (Cadaver) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

32851 Lung Transplant Single Without Cardiopulmonary Bypass 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

32852 Lung Transplant Single with Cardiopulmonary Bypass 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

32853 Lung Transplant Double (Sequential or En Bloc) Without Cardpulm Bypass 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

32854 Lung Transplant Double (Sequential or En Bloc) with CardPulm Bypass 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

32855 Backbench Standard Preparation Of Cadaver Donor Lung Allograft Unilateral 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

32856 Backbench Standard Preparation Of Cadaver Donor Lung Allograft Bilateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

33206 Insertion of new or replacement of permanent Pacemaker with transvenous electrode(s) 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127


855-339-8127

33208 Insertion of new or replacement of permanent Pacemaker with trans venous electrode(s) 0-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33210 Insertion or replacement of temporary leadcatheter ndash single chamber lead 06-04-2019 Premera Blue Cross


33212 Insertion of Pacemaker pulse generator only with existing single lead 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33213 Insertion of Pacemaker pulse generator only dual chamber 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33215 Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (Rt atrial or Rt ventricular) electrode



33216 Insertion of a transvenous electrode single lead 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

33217 Insertion of transvenous electrodes dual leads 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33221 Insertion of pacemaker pulse generator only with existing multiple leads 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33224 Insertion of pacing electrode cardiac venous system for left ventricular pacing with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket removal insertion andor replacement of existing generator)


855-339-8127

33225 Insertion of pacing electrode cardiac venous system for left ventricular pacing at time of insertion of implantable defibrillator or pacemaker pulse generator (eg for upgrade to dual

chamber system) (List separately in addition to code for primary procedure)



33230 Insertion of implantable defibrillator pulse generator only with existing dual leads 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33231 Insertion of implantable defibrillator pulse generator only with existing multiple leads 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33240 Insertion of implantable defibrillator pulse generator only with existing single lead 06-04-2019 Premera Blue Cross Provider Portal

855-339-8127

33249 Insertion or replacement of permanent implantable defibrillator system with transvenous lead(s) single or dual chamber


855-339-8127

33282 Implantation of patient-activated cardiac event recorder 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant including fluoroscopy transseptal puncture catheter placement(s) left atrial angiography left atrial appendage angiography when performed and radiological supervision and interpretation



33930 Donr Cardiectmy- PneumPrepMainHom 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

33933 Backbench Standard Preparation Of Cadaver Donor HeartLung Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

33935 Heart-Lung Transplant W Recipient Cardi 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

33940 Donor cardiectomy (including cold preservation) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

33944 Backbench Standard Preparation Of Cadaver Donor Heart Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

33945 Heart transplant wor without recipient cardiectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

33975 Implantation of Ventricular Assist Device Single Ventricle Support 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

33976 Implantation of Ventricular Assist Device Biventricular Support 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

33979 Insertion Of Ventricular Assist Device Implantable Intracorporeal Single Ventricle 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

33990 Insertion Of Ventricular Assist Device Percutaneous Arterial Access Only 05-01-2018 Premera Blue Cross


33991 Insertion Of Ventricular Assist Device Percutaneous Both Arterial And Venous Access With Transseptal Puncture


Provider Portal

855-339-8127

34841 Endovascular repair of visceral aorta (eg aneurysm pseudoaneurysm dissection penetrating ulcer intramural hematoma or traumatic disruption) by deployment of a

fenestrate



fenestrate



fenestrate including three visceral artery endoprostheses (superior mesenteric celiac

andor renal artery[s])


855-339-8127

34844 Endovascular repair of visceral aorta (eg aneurysm pseudoaneurysm dissection penetrating ulcer intramural hematoma or traumatic disruption) by deployment of a fenestrate including four or more visceral artery endoprostheses (superior mesenteric

celiac andor renal artery[s])




Date


Review

34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg aneurysm pseudoaneurysm dissection penetrating ulcer intramural hematoma or traumatic disruption


855-339-8127



855-339-8127

34847 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg aneurysm

pseudoaneurysm dissection penetrating ulcer intramural hematoma or traumatic

disruption)


Provider Portal

855-339-8127



disruption)


Provider Portal

855-339-8127

36217 Select Cath Plcmt Art3rd Ord Thrc 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

36218 Select Cath Plcmt Art Add 2nd3rd Order 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

36468 1+ Injec-SclerSolutionsSpider Vein Li 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

36470 Injection Sclerosing Solution Single Vein 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

36471 Inject Sclerosing Agent Mult Veins 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

36473 Endovenous ablation therapy of incompetent vein extremity inclusive of all imaging

guidance and monitoring percutaneous mechanochemical first vein treated 10-16-2018 Premera Blue Cross

Provider Portal

855-339-8127

36474 Endovenous ablation therapy of incompetent vein extremity inclusive of all imaging guidance and monitoring percutaneous mechanochemical subsequent vein(s) treated in a single extremity each through separate access sites (List separately in addition to code for

primary procedure)


855-339-8127


Date


Review

36475 Endovenous Ablation Therapy Of Incompetent Vein Extremity Percutaneous Radiofrequency First Vein Treated


855-339-8127

36476 Endovenous Ablation Therapy Incompetent Vein Extremity Percut Radiofreq 2nd amp

Subsequent VeinsSame ExtremSep Sites 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

36478 Endovenous Ablation Therapy Of Incompetent Vein Extremity Percutaneous Laser First Vein Treated


36479 Endovenous Ablation Therapy Incompetent Vein Extremity Percutaneous Laser 2nd amp

Subseq Veins Same Extrem Sep Sites


855-339-8127

36516 Therapeutic Apheresis with Extracorporeal Selective Adsorption or Selective Filtration and Plasma Reinfusion


Provider Portal

855-339-8127

37188 Percutaneous transluminal mechanical thrombectomy vein(s) repeat treatment on

subsequent day of thrombolytic therapy


855-339-8127

37700 Ligation and division of long saphenous vein at saphenofemoral junction or distal interruptions


855-339-8127

37718 Ligation division and stripping short saphenous vein 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

37722 Ligation division and stripping long (greater) saphenous veins from saphenofemoral junction to knee or below


855-339-8127

37735 Ligation amp Strip Saphen+ulcer Unil 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

37760 Ligation Perforators Rad (Linton) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

37761 Ligation of Perforator Vein(s) Subfascial Open Including Ultrasound Guidance When Performed 1 Leg


855-339-8127


Date


Review

37765 Stab Phlebectomy of Varicose Veins One Extremity 10-20 Stab Incisions 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

37766 Stab Phlebectomy of Varicose Veins One Extremity More Than 20 Incisions 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)


855-339-8127

37785 Ligation 2ndary Varicose Vein Unilateral 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

38204 Management of Recipient Hematopoietic Progenitor Cell Donor Search and Cell Acquisition 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

38205 Blood-Derived Hematopoietic Progenitor Cell Harvesting for Transplantation Per Collection Allogenic


855-339-8127

38206 Blood-Derived Hematopoietic Progenitor Cell Harvesting for Transplantation Per Collection Autologous


855-339-8127

38207 Transplant Preparation of Hematopoietic Progenitor Cells Cryopreservation and Storage 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

38208 Transplant Preparation of Hematopoietic Progenitor Cells Thawing of Previously Frozen Harvest


855-339-8127

38209 Transplant Preparation of Hematopoietic Progenitor Cells Washing of Harvest 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

38210 Transplant Preparation of Hematopoietic Progenitor Cells Specific Cell Depletion Within Harvest T- Cell Depletion



38211 Transplant Preparation of Hematopoietic Progenitor Cells Tumor Cell Depletion 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

38212 Transplant Preparation of Hematopoietic Progenitor Cells Red Blood Cell Removal 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

38213 Transplant Preparation of Hematopoietic Progenitor Cells Platelet Depletion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

38214 Transplant Preparation of Hematopoietic Progenitor Cells Plasma (Volume) Depletion 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

38215 Transplant Preparation of Hematopoietic Progenitor Cells Cell Concentration in Plasma

Mononuclear or Buffy Coat Layer


855-339-8127

38230 Harvest Bone Marrow For Transplant 05-01-2018 Premera Blue Cross


38232 Bone Marrow Harvesting For Transplantation Autologous 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

38240 Bone Marrow Trans plantation Allogenic 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

38241 Bone Marrow Transplant Autologous 05-01-2018 Premera Blue Cross


38242 Bone Marrow or Blood-Derived Peripheral Stem Cell Transplantation Allogeneic Donor Lymphocyte Infusions


855-339-8127

41120 Glossectomy less than one-half tongue 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

41500 Fixation of tongue mechanical other than suture (eg K-wire) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

42120 Resect Palateor Extensive Lesion 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

42140 Uvulectomy 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

42145 Uvuloplatopharyngoplasty 05-01-2018 Premera Blue Cross


42160 Destruct Lesion PalateUvula 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

42226 Lengthening of Palate and Pharyngeal Floor 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

42227 Lengthen Palate W Island Flap 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

42235 Repair Anterior Palate Including Vomer Flap 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

42950 Pharyngoplasty 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

42953 Repair Pharyngoesophageal 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

43229 Esophagoscopy flexible transoral with ablation of tumor(s) polyp(s) or other lesion(s) 08-16-2018 Premera Blue Cross Provider Portal

855-339-8127

43270 Esohpagogastroduodenoscopy flexible transoral with ablation of tumor(s) polyp(s) or other lesion(s)



43327 Esophagogastric Fundoplasty Partial Or Complete Laparotomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

43644 Laparoscopy Surg Gastric Restrictive Procedure W Gastric Bypass And Roux -En-Y Gastroenterostomy (Roux Limb

lt= 150 Cm)


855-339-8127


Date


Review

43645 Laparoscopy Surgical Gastric Restrictive Procedure With Gastric Bypass And Small Intestine Reconstruction


855-339-8127

43647 Laparoscopy Surgical Implantation or Replacement of Gastric Neurostimulator Electrodes Antrum


Provider Portal

855-339-8127

43648 Laparoscopy Surgical Revision or Removal of Gastric Neurostimulator Electrodes Antrum 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

43659 Unlisted laparoscopy procedure stomach 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

43770 Laparoscopy surg gastric restrictive procedure placement of adjustable gastric band 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

43771 Laparoscopy surgical gastric restrictive procedure revision of adjustable gastric band component only


855-339-8127

43772 Laparoscopy surgical gastric restrictive procedure removal of adjustable gastric band component only


43773 Laparoscopy surgical gastric restrictive procedure removal and replacementof adjustable gastric band component only


Provider Portal

855-339-8127

43774 Laparoscopy surg gastric restrictive procedure removal of adjustable

gastric band and subcutaneous port components



43775 Laparoscopy Surgical Gastric Restrictive Procedure Longitudinal Gastrectomy (ie Sleeve

Gastrectomy)



43843 Gastroplsty Non Vert-Banded Obesity 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

43845 Gastric Stapling Morbid Obesity 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

43846 Gastric Bypass WRoux-En-Y- Morbid Obesity 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

43847 Gstrc Restricve Prcd w Gstrc Byps F Morbid Obesty wSml Bowel Rcnstn 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

43848 Revision of Gastrc Restrictive Prcd For Morbid Obesity (Separate Prcd) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

43850 Rev Gastroduodenostomy wo Vagotomy 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

43855 Rev Gastroduodenostomy w reconstruction with vagotomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

43860 Rev Gastrojejunostomy wo Vagotomy 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

43865 Gastrojejunostomy with Vagotomy 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

43881 Implantation or Replacement of Gastric Neurostimulator Electrodes Antrum Open 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

43882 Revision or Removal of Gastric Neurostimulator Electrodes Antrum Open 05-01-2018 Premera Blue Cross


44133 Donor Enterectomy Open w Allograft Prep amp Maintenance Living Donor 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

44136 Intestinal Allotransplantation From Living Donor 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

47133 Donor HepatectomyW Prep amp Maintenance-H 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

47135 Transplant Liver (Recipient) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

47140 Donor Hepatectomy with Preparation and Maintenance of Allograft Living Donor Left Lateral Segment Only




Date


Review

47141 Donor Hepatectomy with Preparation and Maintenance of Allograft Living Donor Total Left Lobectomy


855-339-8127

47142 Donor Hepatectomy with Preparation and Maintenance of Allograft Living Donor Total Right Lobectomy


Provider Portal

855-339-8127

47143 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft Without Trisegment Or Lobe Split


855-339-8127

47144 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft W Trisegment Split

Of Graft Into Two Partial Grafts


Provider Portal

855-339-8127

47145 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft With Lobe Split Of

Graft Into Two Partial Grafts


855-339-8127

47146 Backbench Reconstruction Of Cadaver Or Living Donor Liver Gr aft Prior To Allotransplantation Venous Anastomosis Each


47147 Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To

Allotransplantation Arterial Anastomosis Each


Provider Portal

855-339-8127

47370 Laparoscopy Surgical Ablation Of One Or More Liver Tumor(S) Radiofrequency 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

47371 Laparoscopy Surgical Ablation Of One Or More Liver Tumor(S) Cryosurgical 05-01-2018 Premera Blue Cross


47379 Unlisted Laparoscopic Procedure Liver 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

47380 Ablation Open Of One Or More Liver Tumor(S) Radiofrequency 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

47381 Ablation Open Of One Or More Liver Tumor(S) Cryosurgical 05-01-2018 Premera Blue Cross



Date


Review

47382 Ablation One Or More Liver Tumor(S) Percutaneous Radiofrequency 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

47383 Ablation 1 or more liver tumor(s) percutaneous cryoablation 05-01-2018 Premera Blue Cross


48550 Donor Pancreatectomy For Transplantation 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

48551 Backbench Standard Preparation Of Cadaver Donor Pancreas Allograft 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

48552 Backbench Reconstruction Of Cadaver Donor Pancreas Allograft Prior To Transplantation

Venous Anastomosis Each


Provider Portal

855-339-8127

48554 Transplantation of Pancreatic Allograft 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

48556 Removal of Transplanted Pancreatic Allograft 05-01-2018 Premera Blue Cross


50300 Nephrectomy Cadaver Donor 05-01-2018 Premera Blue Cross


50320 Donor Nephrectomy from Living DonorUnil 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

50323 Backbench Standard Preparation Of Cadaver Donor Renal Allograft 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

50325 Backbench Standard Preparation Of Living Donor Renal Allograft (Open Or Laparoscopic) 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

50327 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation Venous Anastomosis Each


50328 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To

Transplantation Arterial Anastomosis Each 05-01-2018 Premera Blue Cross



Date


Review


Transplantation Ureteral Anastomosis Each 05-01-2018 Premera Blue Cross


50340 Nephrectomy Recipient Unilateral 05-01-2018 Premera Blue Cross


50360 Transplant Renal Homograft 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

50365 Renal HomotxplntImplnt GftwRecipient Ne 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

50370 Removal of Transplanted Homograft 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

50380 Transplant Renal Autograft 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

50547 Laparoscopy surgical donor nephrectomy from living donor 05-01-2018 Premera Blue Cross


52287 Cystourethroscopy With Injection(s) For Chemodenervation of the Bladder 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

53860 Transurethral Radiofrequency Micro- Remodeling Of The Female Bladder Neck And Proximal Urethra


54400 Insertion of penile prosthesis non-inflatable (semi -rigid) 06-04-2019 Premera Blue Cross Provider Portal 855-339-8127

54401 Insertion of penile prosthesis inflatable (self-contained) 06-04-2019 Premera Blue Cross Provider Portal 855-339-8127

54405 Insertion of multi -component inflatable penile prosthesis including placement of pump

cylinders and reservoir 06-04-2019 Premera Blue Cross

Provider Portal

855-339-8127

55873 Cryosurgical Ablation of the Prostate (Incl Ultrasonic Probe Placement) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

55175 Scrotoplasty simple 04-16-2019 Premera Blue Cross Provider Portal

855-339-8127

55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement

application with or without cystoscopy


AIM Provider Portal

866-666-0776

55920 Placement of needles or catheters into pelvic organs andor genitalia (except prostate) for

subsequent interstitial radioelement application 01-01-2019 AIM Specialty Health

AIM Provider Portal 866-666-0776

57155 Insertion of uterine tandem andor vaginal ovoids for clinical brachytherapy 01-01-2019 AIM Specialty Health


57156 Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy 01-01-2019 AIM Specialty Health


57335 Vaginoplasty for intersex state 04-16-2019 Premera Blue Cross

Provider Portal

855-339-8127

58346 Insertion of Heyman capsules for clinical brachytherapy 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776

61517 Implantation of Brain Intracavitary Chemotherapy Agent 05-01-2018 Premera Blue Cross


61650 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than

for thrombolysis arterial including catheter placement diagnostic angiography and imaging guidance initial vascular territory


Provider Portal

855-339-8127

61651 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis arterial including catheter placement diagnostic angiography and

imaging guidance each additional vascular territory (List separately in addition to


61850 Twst DrlBrr Hole-Impl Eleccorticl 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

61860 Craniectomy or craniotomy for implantation of neurostimulator electrodes cerebral cortical


855-339-8127


Date


Review

61863 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array wo Intraop

Microelectrode Recording First Array


855-339-8127

61864 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array wo Intraop

Microelectrode Recording ea addl Array


Provider Portal

855-339-8127

61867 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array w Intraop



855-339-8127

61868 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array w Intraop



Provider Portal

855-339-8127

61880 RevisRemv IntracrNeurost Elec trod 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

62287 Asp Percutaneous Diskectomy OneMult Lev 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

62290 Inj Proc Diskography Ea Level Lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

62291 Inject For Diskography Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

62320 Injection(s) of diagnostic or therapeutic substance(s) (eg anesthetic antispasmodic

opioid steroid other solution) not including neurolytic substances including needle or

catheter placement interlaminar epidural or subarachnoid cervical or thoracic without

imaging guidance



62321 Injection(s) of diagnostic or therapeutic substance(s) (eg anesthetic antispasmodic opioid steroid other solution) not including neurolytic substances including needle or catheter placement interlaminar epidural or subarachnoid cervical or thoracic with

imaging guidance (ie fluoroscopy or CT)





catheter placement interlaminar epidural or subarachnoid lumbar or sacral (caudal)

without imaging guidance


866-666-0776


Date


Review



catheter placement interlaminar epidural or subarachnoid lumbar or sacral (caudal) with



866-666-0776

63001 Laminec-ExplDecomp12 Segmcerv 05-01-2018 Premera Blue Cross


63003 Decompress Spine lt2 Seg Thoracic 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63005 Laminec=explDecomp12 Segmlumb 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63011 Laminec-ExplDecomp12 Segmsacr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

63012 LaminectomyRem FacetsLumbar (Gill Type) 05-01-2018 Premera Blue Cross


63015 Laminec-ExplDec3+segcerv 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63016 Decompress Spine gt2 Seg Thoracic 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63017 Laminec-ExplDec3+seg lumbar 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63020 Exc Iv Disk Cervical Unilat 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63030 Exc Iv Disk Lumbar Unilat 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63035 Exc Iv Disk CervicalLumb gt1 Space 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

63040 Laminotomy W Dec Nrv Rtsreexcerv 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63042 Laminotomy W Dec Nrv Rtsreexlumb 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63043 Laminotomy w Decompressn Nerve Root Reexplor Ea Addl Cerv Interspace 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63044 Laminotomy w Decompressn Nerve Root Reexplor Ea Addl Lumb Interspace 05-01-2018 Premera Blue Cross


63045 Laminectomy W Facetectomy- Cervical 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63046 Laminect 1 Segm thoracic 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63047 Laminectomy W Facetectomy- Lumbar 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63048 LamFacetectForaminotea AdtlSeg 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63050 Laminoplasty Cervical With Decompression Of The Spinal Cord Two Or More Vertebral Segments


Provider Portal

855-339-8127

63051 Laminoplasty Cerv W Decompression Of Spinal Cord 2 Or gt Verteb Segments W

Reconstruction Of Posterior Bony Elements


855-339-8127

63055 Decompress Spine Transpedic- Thorac 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63056 Transped AppDecompsglelumb 05-01-2018 Premera Blue Cross


63057 Decomp Spine Transpedic-Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

63064 Decompress Spine Costoverteb 1 Seg 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63066 Decomp Spine Costoverteb-Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

63075 DiskectomyAnteWDecomp CordRoot cervical 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63076 Exc Iv Disk Ant Cervical gt1 Seg 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63077 DiskectomyAnteWDecomp CordRoot thoracic 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63078 Exc Iv Disk Ant Thoracic-Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

63081 Vert Corpectomy PartComp anter approach w decompression cervical single segment 05-01-2018 Premera Blue Cross


63082 Vert Corpectomy PartComp anter approach w decompression cerv each additional segment


Provider Portal

855-339-8127

63085 Vert Corpect PartComp Transthoracic 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63086 Corpecto Verteb Thoracic Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

63087 VertCorpectthoracolumbarTho rLumbars 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63090 VertCorpecperit oneal Apprsingle 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63101 Vertebral Corpectomy Lateral Extracavitary Approach w Decompression of Spinal CordNerve Roots Thoracic Sgl Segment


855-339-8127


Date


Review

63103 Vertebral Corpectomy Lateral Extracavitary Approach w Decompression Spinal

CordNerve Rts ThoracicLumbar ea addl Seg


855-339-8127

63170 Laminectomy W MyelotomycervThoracicTh 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63180 Section Dentate Lig Cervical lt2 Seg 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63182 LaminecSection Ligaments WWo GrftCerv 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63185 Rhizotomy lt2 Segments 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63190 Rhizotomy gt2 Segments 05-01-2018 Premera Blue Cross


63191 Section Spinal Accessory Nerve Unil 05-01-2018 Premera Blue Cross


63194 Cordotomy Unilat 1 Stage Cervical 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63195 Cordotomy Unilat 1 Stage Thoracic 05-01-2018 Premera Blue Cross


63196 Cordotomy Bilat 1 Stage Cervical 05-01-2018 Premera Blue Cross


63197 Laminect W Cordotomyboth Tracts1 Stgt 05-01-2018 Premera Blue Cross


63198 Cordotomy Bilat 2 Stage Cervical 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63199 LaminectW Cordotmyboth Tracts2 Stgth 05-01-2018 Premera Blue Cross



Date


Review

63200 Release Tethered Spinal Cord 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63265 Laminectintraspinal Lesioncerv 05-01-2018 Premera Blue Cross


63266 Exc Les Intraspin Extradur- Thoracic 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63267 Laminectintraspinal Lesionlumb 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63270 Lamin-Exc IntraspLesIntrad urce rv 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63271 Exc Les Intraspin Intradur- Thoracic 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63272 Lamin-Exc IntraspLesIntradurlumb 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63275 LamBxExc IntraspNeoe xtra d ur Ce r 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63276 Exc Intraspin Neopl Extradur- Thorac 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63280 LamBxExc IntNeointraE xtra Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

63281 Exc Intraspin Neopl Extramed- Thorac 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63285 LamBxExc InNeointrad ur Im Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

63286 Exc Intraspin Neopl Intramed- Thorac 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

63287 LamBxExc NeointradurImThoracol 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63295 Osteoplastic Reconstruction of Dorsal Spinal Elements Following Primary Intraspinal Procedure (List separately in addition to code for primary procedure)


855-339-8127

63300 VertCorpect my1 Segextradu rl Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

63301 Corpectomy Verteb-Thorac Transthor 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63302 VertCorpect m1 extra Th or- Thoracol 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63304 VertCorpect my1 Segintradurl Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


855-339-8127

63306 VertCorp1in tra du rT hor- Thoracol 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63307 VertCorpecExc Les 1i ntra dur Lu mb Sac- 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

63308 Vertebral Corpectomy ea Add Segment 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

63650 Percutaneous implantation of neurostimulator electrode array epidural 01-01-2018 AIM Specialty Health


63655 Laminectomy for implantation of neurostimulator electrodes platepaddle epidural 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

63663 Revision including replacement when performed of spinal neurostimulator electrode

percutaneous array(s) including fluoroscopy when performed


AIM Provider Portal

866-666-0776


Date


Review


platepaddle(s) placed via laminotomy or laminectomy including fluoroscopy when

performed


AIM Provider Portal

866-666-0776

63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver direct or inductive coupling


866-666-0776

63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

64479 Injection(s) anesthetic agent andor steroid transforaminal epidural with imaging

guidance (fluoroscopy or CT) cervical or thoracic single level


AIM Provider Portal

866-666-0776


guidance (fluoroscopy or CT) cervical or thoracic each additional level (List separately in

addition to code for primary procedure)


AIM Provider Portal

866-666-0776


guidance (fluoroscopy or CT) lumbar or sacral single level




guidance (fluoroscopy or CT) lumbar or sacral each additional level (List separately in



866-666-0776

64490 Injection(s) diagnostic or therapeutic agent paravertebral facet (zygapophysial) joint (or

nerves innervating that joint) with image guidance (fluoroscopy or CT) cervical or thoracic

single level


866-666-0776


nerves innervating that joint) with image guidance (fluoroscopy or CT) cervical or thoracic second level (List separately in addition to code for primary procedure)


866-666-0776

64492 Injection(s) diagnostic or therapeutic agent paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT) cervical or thoracic

third and any additional level(s) (List separately in addition to code for primary procedure)


866-666-0776

64493 Injection(s) diagnostic or therapeutic agent paravertebral facet (zygapophyseal) joint (or

nerves innervating that joint) with image guidance (fluoroscopy or CT) lumbar or sacral

single level



64494 Injection(s) diagnostic or therapeutic agent paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT) lumbar or sacral second level (List separately in addition to code for primary procedure)


866-666-0776


Date


Reviewinset

64495 Injection(s) diagnostic or therapeutic agent paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT) lumbar or s acral third and any additional level(s) (List separately in addition to code for primary procedure)



64510 Injection anesthetic agent stellate ganglion (cervical sympathetic) 01-01-2019 AIM Specialty Health


64520 Injection anesthetic agent lumbar or thoracic (paravertebral sympathetic) 01-01-2019 AIM Specialty Health AIM Provider Portal

866-666-0776

64553 Percutaneous implantation of neurostimulator electrode array cranial nerve 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

64561 Percutaneous implantation of neurostimulator electrode array sacral nerve

(transforaminal placement) including image guidance if performed


64568 Incision for implantation of cranial nerve (eg vagus nerve) neurostimulator electrode a rray and pulse generator



64569 Revision or replacement of cranial nerve (eg vagus nerve) neurostimulator electrode array including connection to existing pulse generator


64570 Removal of cranial nerve (eg vagus nerve) neurostimulator electrode array and pulse generator



64581 Incision for implantation of neurostimulator electrode array sacral nerve (transforaminal placement)



64590 Insertionreplacement of periph or gastric neurostimulator pulse generator or receiver direct or inductive coupling


64595 Revisionremoval of periph or gastric neurostimulator pulse generator or receiver 05-01-2018 Premera Blue Cross


64612 Dest Neurolytic Agent Muscle Enervated 05-01-2018 Premera Blue Cross


64616 Chemodenervation of muscle(s) neck muscle(s) excluding muscles of the larynx unilateral (eg for cervical dystonia spasmodic torticollis)




Date


Review

64617 Chemodenervation of muscle(s) larynx unilateral percutaneous (eg for spasmodic

dysphonia) includes guidance by needle electromyography when performed



64633 Destruction by neurolytic agent paravertebral facet joint nerve(s) with imaging guidance

(fluoroscopy or CT) cervical or thoracic single facet joint


AIM Provider Portal

866-666-0776


(fluoroscopy or CT) cervical or thoracic each additional facet joint (List separately in



866-666-0776


(fluoroscopy or CT) lumbar or sacral single facet joint


866-666-0776


(fluoroscopy or CT) lumbar or sacral each additional facet joint (List separately in addition

to code for primary procedure)


866-666-0776

64642 Chemodenervation of one extremity 1-4 muscle(s) 05-01-2018 Premera Blue Cross


64643 Chemodenervation of one extremity each additional extremity 1 -4 muscle(s) (List

separately in addition to code for primary procedure)


64644 Chemodenervation of one extremity 5 or more muscle(s) 05-01-2018 Premera Blue Cross


64645 Chemodenervation of one extremity each additional extremity 5 or more muscle(s) (List



64646 Chemodenervation of trunk muscle(s) 1-5 muscle(s) 05-01-2018 Premera Blue Cross


64647 Chemodenervation of trunk muscle(s) 6 or more muscle(s) 05-01-2018 Premera Blue Cross


64650 Chemodenervation of eccrine glands both axillae 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

64653 Chemodenervation of eccrine glands other area(s) (eg scalp face neck) per day 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

66820 Discission of secondary membranous cataract (opacified posterior lens capsule andor anterior hyaloid) stab incision technique (Ziegler or Wheeler knife)


855-339-8127

66821 Discission of secondary membranous cataract (opacified posterior lens capsule andor anterior

hyaloid) laser surgery (eg YAG laser) (1 or more stages) 04-01-2020 Premera Blue Cross


66830 Removal of secondary membranous cataract (opacified posterior lens capsule andor anterior

hyaloid) with corneo-scleral section with or without iridectomy (iridocapsulotomy iridocapsulectomy)


66840 Removal of lens material aspiration technique 1 or more stages



66850 Removal of lens material phacofragmentation technique (mechanical or ultrasonic) (eg phacoemulsification) with aspiration


66852 Removal of lens material pars plana approach with or without vitrectomy



66920 Removal of lens material intracapsular



66930 Removal of lens material intracapsular for dislocated lens


66940 Removal of lens material extracapsular (other than 66840 66850 66852)


66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure) manual or mechanical technique (eg irrigation and aspiration or phacoemulsification) complex requiring devices or techniques not generally used in routine cataract surgery (eg iris expansion

device suture support for intraocular lens or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage


66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)



66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure)

manual or mechanical technique (eg irrigation and aspiration or phacoemulsification)



Date


Review

67218 Destruction of localized lesion of retina (eg macular edema tumors) 1 or more sessions radiation by implantation of source (includes removal of source)


866-666-0776

67900 Repair Brow Ptosis (SupraciliaryMidCor) 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

67901 Repair Blepharoptosis Frontalis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

67902 Rep Blepharoptosis Frontalis+sling 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

67903 Rep Blephadvinternal Appr 05-01-2018 Premera Blue Cross


67904 Rep Blepharoptosis Levator External 05-01-2018 Premera Blue Cross


67906 RepBlephsupRectus TechFascSlng 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127 67908 RepBlephc onju nct-T ars o- LevResec 05-01-2018 Premera Blue Cross


69714 Implantation osseointetrated implant temporal bone with percutaneous attachment to

external speech processorcochlear stimulator without mastoidectomy


69930 Cochlear Device Implantation WWo Masto 05-01-2018 Premera Blue Cross


70336 MRI of the Temporomandibular Joint(s) 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70450 CT of head without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70460 CT of head with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70470 CT of head without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health



Date


Review

70480 CT of orbit sella or posterior fossa and outer middle or inner ear without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70481 CT of orbit sella or posterior fossa and outer middle or inner ear with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776 70482 CT of orbit sella or posterior fossa and outer middle or inner ear without contrast

followed by re-imaging with contrast


AIM Provider Portal

866-666-0776

70486 CT of maxillofacial area without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70487 CT of maxillofacial area with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70488 CT of maxillofacial area without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70490 CT soft tissue neck without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70491 CT soft tissue neck with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70492 CT soft tissue neck without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70496 Computed tomographic angiography head with contrast material(s) including noncontrast

images if performed and image post processing


866-666-0776

70498 CTA neck with contrast material(s) including noncontrast images if

performed and image post- processing


866-666-0776

70540 MRI orbit face and neck without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70542 MRI orbit face and neck with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70543 MRI orbit face and neck without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health



Date


Review

70544 Magnetic resonance angiography head without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70545 Magnetic resonance angiography head with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776 70546 Magnetic resonance angiography head without contrast followed by re - imaging with

contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

70547 MRA neck without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70548 MRA neck with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70549 MRA neck without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70551 MRI Head without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70552 MRI Head with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70553 MRI Head without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

70554 Magnetic resonance imaging brain functional MRI including test selection and administration of repetitive body part movement andor visual stimulation requiring

physician or psychologist administration of entire neurofunctional testing


866-666-0776

70555 Magnetic resonance imaging brain functional MRI including test selection and administration of repetitive body part movement andor visual stimulation requiring physician or psychologist administration of entire neurofunctional testing


866-666-0776

71250 Chest CT without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776 71260 Chest CT with contrast 01-01-2018 AIM Specialty Health


71270 Chest CT without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776


Date


Review

71275 CTA of chest (non-coronary) with contrast material(s) including noncontrast images if performed and image post-processing


866-666-0776

71550 MRI chest without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776 71551 MRI chest with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

71552 MRI chest without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

71555 MRA of chest (excluding the myocardium) without contrast followed by re -imaging with

contrast


866-666-0776

72125 CT of cervical spine without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

72126 CT of cervical spine with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

72127 CT of cervical spine without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72128 CT of thoracic spine without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

72129 CT of thoracic spine with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72130 CT of thoracic spine without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72131 CT of lumbar spine without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72132 CT of lumbar spine with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776


Date


Review

72133 CT of lumbar spine without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health


72141 MRI of cervical spine without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

72142 MRI of cervical spine with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72146 MRI of thoracic spine without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72147 MRI of thoracic spine with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72148 MRI of lumbar spine without contrast 01-01-2018 AIM Specialty Health


72149 MRI of lumbar spine with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

72156 MRI of cervical spine without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

72157 MRI of thoracic spine without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72158 MRI of lumbar spine without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health


72159 Magnetic resonance angiography of spinal canal 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72191 Computed tomographic angiography pelvis with contrast material(s) including non-

contrast images if performed and image post- processing


AIM Provider Portal

866-666-0776

72192 CT of pelvis without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776


Date


Review

72193 CT of pelvis with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72194 CT of pelvis without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health


72195 MRI of pelvis without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

72196 MRI of pelvis with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

72197 MRI of pelvis without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health


72198 Magnetic resonance angiography pelvis without contrast followed by re -imaging with contrast


866-666-0776

72285 Diskography Cervical Rad SampI 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

72295 Diskography Lumbar Rad SampI 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

73200 CT upper extremity without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

73201 CT upper extremity with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73202 CT upper extremity without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health


73206 Computed tomographic angiography upper extremity with contrast material(s) including

non-contrast images if performed and image post-processing




Date


Review

73218 MRI upper extremity non-joint without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73219 MRI upper extremity non-joint with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73220 MRI upper extremity non-joint without contrast followed by re- imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73221 MRI upper extremity any joint without contrast 01-01-2018 AIM Specialty Health


73222 MRI upper extremity any joint with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

73223 MRI upper extremity any joint without contrast followed by re -imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73225 Magnetic resonance angiography upper extremity without and with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73700 CT lower extremity without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73701 CT lower extremity with contrast 01-01-2018 AIM Specialty Health


73702 CT lower extremity without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

73706 Computed tomographic angiography lower extremity with contrast material(s) including

noncontrast images if performed and image post-processing 01-01-2018 AIM Specialty Health


73718 MRI lower extremity other than joint without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776


Date


Review

73719 MRI lower extremity other than joint with contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

73720 MRI lower extremity other than joint without contrast followed by re - imaging with contrast


AIM Provider Portal

866-666-0776

73721 MRI lower extremity any joint without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73722 MRI lower extremity any joint with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73723 MRI lower extremity any joint without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

73725 Magnetic resonance angiography lower extremity without and with contrast 01-01-2018 AIM Specialty Health


74150 CT abdomen without contrast 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

74160 CT abdomen with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74170 CT abdomen without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74174 Computed tomographic angiography abdomen and pelvis with contrast material(s)

including noncontrast images if performed and image postprocessing 01-01-2018 AIM Specialty Health


74175 Computed tomographic angiography abdomen with contrast material(s) including non -



866-666-0776

74176 CT of abdomen and pelvis without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776


Date


Review

74177 CT of abdomen and pelvis with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74178 CT of abdomen and pelvis without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74181 MRI of abdomen without contrast 01-01-2018 AIM Specialty Health


74182 MRI of abdomen with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74183 MRI of abdomen without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74185 Magnetic resonance angiography abdomen without or with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74261 Diagnostic CT colonography without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

74262 Diagnostic CT colonography with contrast including non-contrast images if performed 01-01-2018 AIM Specialty Health


74263 Screening CT colonography including image post-processing 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

74712 Magnetic resonance (eg proton) imaging fetal including placental and maternal pelvic

imaging when performed single or first gestation


866-666-0776 74713 Magnetic resonance (eg proton) imaging fetal including placental and maternal pelvic

imaging when performed each additional gestation (List separately in addition to code for primary procedure)


AIM Provider Portal

866-666-0776

75557 Cardiac MRI for morphology and function without contrast material 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

75559 Cardiac MRI for morphology and function without contrast material with stress imaging 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776


Date


Review

75561 Cardiac MRI for morphology and function without contrast material followed by contrast material


866-666-0776

75563 Cardiac MRI for morphology and function without contrast material followed by contrast

material with stress imaging 01-01-2018 AIM Specialty Health


75565 Add-on code to be used in conjunction with 75557 75559 75561 and 75563 As such this code does not require separate review


866-666-0776

75571 Computed tomography heart without contrast material with quantitative evaluatio n of coronary artery calcium


866-666-0776

75572 Computed tomography heart with contrast material for evaluation of cardiac structure

and morphology (including 3-D image post-processing assessment of cardiac function and

evaluation of venous structures if performed)


866-666-0776

75573 Computed tomography heart with contrast material for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3-D post-processing assessment of left ventricular cardiac function right ventricular structure and function and




75574 Computed tomographic angiography heart coronary arteries and bypass grafts (where present) with contrast material including 3-D image post- processing (including evaluation of cardiac structure and morphology assessment of cardiac function and evaluation of

venous structures if performed)



75635 Computed tomographic angiography abdominal aorta and bilateral iliofemoral lower

extremity runoff with contrast material(s) including noncontrast images if performed

and image post-processing


866-666-0776

75665 Angiography carotid cerebral unilateral radiological supervision and interpretation 05-01-2018 Premera Blue Cross


75685 Angiography Vertebral Cervical Intracran 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

76376 3D rendering w interpretationand reporting of CT MRI US or other Tomographyic

modality with image postprocessing under concurrent supervision


Provider Portal

855-339-8127

76380 CT limited or localized follow-up study 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

76390 Magnetic Resonance Spectroscopy (MRS) 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

77014 CT guidance for placement of radiation therapy fields 01-01-2019 AIM Specialty Health AIM Provider Portal

866-666-0776

77058 MRI of breast without andor with contrast material(s) unilateral 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

77059 MRI of breast without andor with contrast material(s) bilateral 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

77078 Computed tomography bone mineral density study 1 or more sites axial skeleton (eg hips pelvis spine)


866-666-0776

77084 MRI of bone marrow blood supply 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

77295 3-dimensional radiotherapy plan including dose-volume histograms 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776

77301 Intensity modulated radiation therapy plan including dose volume histogram for target and

critical structure partial tolerance specifications (IMRT treatment plan)


AIM Provider Portal

866-666-0776

77316 Brachytherapy isodose plan simple (1-4 sources or 1 channel) includes basic dosimetry

calculations (Do not bill 77300)


AIM Provider Portal

866-666-0776

77317 Brachytherapy isodose plan intermediate (5-10 sources or 2-12 channels) includes basic

dosimetry calculation (Do not bill 77300)


AIM Provider Portal

866-666-0776

77318 Brachytherapy isodose plan complex (over 10 sources or over 12 channels) includes basic

dosimetry calculations (Do not bill 77300)



77338 Multi-leaf collimator (MLC) devise(s) for intensity modulated radiation therapy (IMRT) design and construction per IMRT plan


866-666-0776

77370 Special medical radiation physics consultation 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776


Date


Review

77371 Radiation treatment delivery stereotactic radiosurgery (SRS) complete course of treatment

of cranial lesion(s) consisting of 1 session multi -source Cobalt 60 based


AIM Provider Portal

866-666-0776


of cranial lesion(s) consisting of 1 session linear accelerator based 01-01-2019 AIM Specialty Health


77373 Stereotactic body radiation therapy treatment delivery per fraction to 1 or more lesions including image guidance entire course not to exceed 5 fractions


AIM Provider Portal

866-666-0776

77385 Intensity modulated radiation treatment delivery (IMRT) includes guidance and tracking when performed simple



77386 Intensity modulated radiation treatment delivery (IMRT) includes guidance and tracking when performed complex



77387 Guidance for localization of target volume for delivery of radiation treatment delivery includes intrafraction tracking when performed


AIM Provider Portal

866-666-0776

77402 Radiation treatment delivery up to 5 MeV simple All of the following criteria are met (and

none of the complex or intermediate criteria are met) single treatment area one or two

ports and two or fewer simple blocks


866-666-0776

77407 Radiation treatment delivery up to 5 MeV intermediate Any of the following criteria are met (and none of the complex criteria are met) 2 separate treatment areas 3 or more

ports on a single treatment area or 3 or more simple blocks


AIM Provider Portal

866-666-0776

77412 Radiation treatment delivery up to 5 MeV complex Any of the following criteria are met 3 or more separate treatment areas custom blocking tangential ports wedges rotational beam field-in-field or other tissue compensation that does not meet IMRT guidelines or

electron beam



77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of

treatment consisting of 1 session)


866-666-0776

77435 Stereotactic body radiation therapy treatment management per treatment course to 1 or

more lesions including image guidance entire course not to exceed 5 fractions


AIM Provider Portal

866-666-0776

77470 Special treatment procedure (eg total body irradiation hemibody radiation per oral or endocavitary irradiation)


866-666-0776


Date


Review

77520 Proton beam delivery to a sgl treatment area sgl port custom block 05-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

77522 Proton Treatment Delivery Simple with Compensation 05-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

77523 Proton beam delivery to one or two treatment areas two or more ports two or more custom blocks



77525 Proton Treatment Delivery Complex 05-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

77761 Intracavitary radiation source application simple 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776

77762 Intracavitary radiation source application intermediate 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776

77763 Intracavitary radiation source application complex 01-01-2019 AIM Specialty Health


77767 Remote afterloading high dose rate radionuclide skin surface brachytherapy includes basic dosimetry when performed lesion diameter up to 20 cm or 1 channel



77768 Remote afterloading high dose rate radionuclide skin surface brachytherapy includes basic

dosimetry when performed lesion diameter over 20 cm and 2 or more channels or

multiple lesions



77770 Remote afterloading high dose rate radionuclide interstitial or intracavitary

brachytherapy includes basic dosimetry when performed 1 channel


Provider Portal

855-339-8127


brachytherapy includes basic dosimetry when performed 2-12 channels


855-339-8127


brachytherapy includes basic dosimetry when performed over 12 channels


855-339-8127


Date


Review

77778 Interstitial radiation source application complex includes supervision handling loading of

radiation source when performed


AIM Provider Portal

866-666-0776

78451 Myocardial perfusion imaging tomographic (SPECT) (including attenuation correction qualitative or quantitative wall motion ejection fraction by first pass or gated technique

additional quantification when performed) single study at rest or stress (exercise or pharmacologic)


AIM Provider Portal

866-666-0776

78452 Myocardial perfusion imaging tomographic (SPECT) (including attenuation correction qualitative or quantitative wall motion ejection fraction by first pass or gated technique additional quantification when performed) single study at rest or stress)


866-666-0776

78453 Myocardial perfusion imaging planar (including qualitative or quantitative wall motion

ejection fraction by first pass or gated technique additional quantification when

performed) single study at rest or stress (exercise or pharmacologic)



78454 Myocardial perfusion imaging planar (including qualitative or quantitative wall motion ejection fraction by first pass or gated technique additional quantification when performed) multiple studies at rest andor stress (exercise or pharmacologic) andor

redistribution andor rest reinjection


AIM Provider Portal

866-666-0776

78459 PET myocardial metabolic evaluation 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

78466 Planar infarct avid qualitative or quantitative 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78468 Planar infarct avid with ejection fraction by first pass technique 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

78469 SPECT infarct avid with or without quantification 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

78472 Gated equilibrium planar single study wall motion plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78473 Gated equilibrium planar multiple studies wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

78481 First pass technique single study wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776


Date


Review

78483 First pass technique multiple studies wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78491 PET myocardial perfusion single study 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78492 PET myocardial perfusion multiple studies 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78494 Gated equilibrium SPECT at rest wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

78496 This code is an add-on code to be used in conjunction with 78472 As such this code does not require separate review


866-666-0776

78608 PET brain metabolic evaluation 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78609 PET brain perfusion evaluation 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78811 PET imaging limited area 01-01-2018 AIM Specialty Health


78812 PET imaging skull to mid-thigh 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

78813 PET imaging whole body 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

78814 PET imaging with concurrently acquired CT for attenuation correction and anatomic localization limited area


866-666-0776

78815 PET imaging with concurrently acquired CT for attenuation correction and anatomic localization skull base to mid- thigh


AIM Provider Portal

866-666-0776


Date


Review

78816 PET imaging with concurrently acquired CT for attenuation correction and anatomic localization whole body


866-666-0776

81162 BRCA1 BRCA2 (breast cancer 1 and 2) (eg hereditary breast and ovaria n cancer) gene

analysis full sequence analysis and full duplicationdeletion analysis


855-339-8127

81200 Aspa (Aspartoacylase) (Eg Canavan Disease) Gene Analysis Common Variants (Eg E285A Y2 31X)


Provider Portal

855-339-8127

81201 APC (Adenomatous Polyposis Coli) Gene Analysis Full Gene Sequence 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81202 APC (Adenomatous Polyposis Coli) Gene Analysis Known Familial Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81203 APC (Adenomatous Polyposis Coli) Gene Analysis DuplicationDeletion Variants 05-01-2018 Premera Blue Cross


81205 Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1 Beta Polypeptide) Gene Analysis Common Variants



81210 Braf (V-Raf Murine Sarcoma Viral Oncogene Homolog B1) (Eg Colon Cancer) Gene Analysis V600E Variant


855-339-8127

81211 Brca1 Brca2 Gene Analysis Full Sequence Analysis And Common DuplicationDeletion Variants In Brca1


855-339-8127

81212 Brca1 Brca2 Gene Analysis 185Delag 5385Insc 6174Delt Variants 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

81214 Brca1 Gene Analysis Full Sequence Analysis And Common DuplicationDeletion Variants 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81215 Brca1 (Breast Cancer 1) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis Known Familial Variant



81216 Brca2 (Breast Cancer 2) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis Full Sequence Analysis


855-339-8127


Date


Review



855-339-8127

81225 Cyp2C19 (Cytochrome P450 Family 2 Subfamily C Polypepti de 19) Gene Analysis Common Variants



81226 Cyp2D6 (Cytochrome P450 Family 2 Subfamily D Polypeptide 6) Gene Analysis Common Variants


855-339-8127

81227 Cyp2C9 (Cytochrome P450 Family 2 Subfamily C Polypeptide 9) GeneAnalysis Common Variants (Eg -2 -3 -5 -6)


Provider Portal

855-339-8127

81228 Cytogenomic Constitutional (Genome- Wide) Microarray Analysis Interrogation Of

Genomic Regions For Copy Number Variants


855-339-8127

81229 Cytogenomic Constitutional Microarray AnalysisInterrog Genomic Regns For Copy Numbr

amp Sgl Nuctide Polymorphism Variants


Provider Portal

855-339-8127

81235 EGFR (epidermal growth factor receptor) (eg non-small cell lung cancer) gene analysis

common variants (eg exon 19 LREA deletion L858R T790M G719A G719S L861Q)


855-339-8127

81240 F2 (Prothrombin Coagulation Factor Ii) (Eg Hereditary Hypercoagulability) Gene Analysis 20210GgtA Variant


81241 F5 (Coagulation Factor V) (Eg Hereditary Hypercoagulability) Gene Analysis Leiden Variant 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81243 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles


81244 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis Characterization Of Alleles 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81250 G6Pc (Glucose-6-Phosphatase Catalytic Subunit) Gene Analysis Common Variants (Eg R83C Q347X)


855-339-8127

81255 Hexa (Hexosaminidase A [Alpha Polypeptide]) Gene Analysis Common Variants (Eg

1278Instatc 1421+1GgtC G269S)


855-339-8127


Date


Review

81256 Hfe (Hemochromatosis) (Eg Hereditary Hemochromatosis) Gene Analysis Common Variants (Eg C282Y H63D)


855-339-8127

81260 Inhibtr Of Kappa Light Plypeptide Gene Enhancr In B-Cells Kinase Complex-Assoc Protein

Gene Analysis Common Variants



81275 Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg Carcinoma) Gene Analysis Variants In Codons 12 And 13


81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg carcinoma) gene analysis

additional variant(s) (eg codon 61 codon 146)


855-339-8127

81280 Long Qt Syndrome Gene Analyses Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81281 Long Qt Syndrome Gene Analyses Known Familial Sequence Variant 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81282 Long Qt Syndrome Gene Analyses DuplicationDeletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81287 MGMT methylation analysis 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81288 MLH1 (mutL homolog 1 colon cancer nonpolyposis type 2) (eg hereditary non -polyposis colorectal cancer Lynch syndrome) gene analysis promoter methylation analysis


81290 Mcoln1 (Mucolipin 1) (Eg Mucolipidosis Type Iv) Gene Analysis Common Variants (Eg Ivs3- 2AgtG Del64Kb)


855-339-8127

81291 Mthfr (510- Methylenetetrahydrofolate Reductase) (Eg Hereditary Hypercoagulability)



855-339-8127

81292 Mlh1 (Mutl Homolog 1 Colon Cancer Nonpolyposis Type 2) Gene Analys is Full Sequence Analysis


81293 Mlh1 (Mutl Homolog 1 Colon Cancer Nonpolyposis Type 2) Gene Analysis Known Familial Variants


855-339-8127


Date


Review

81294 Mlh1 (Mutl Homolog 1 Colon Cancer Nonpolyposis Type 2) Gene Analysis DuplicationDeletion Variants


855-339-8127

81295 Msh2 (Muts Homolog 2 Colon Cancer Nonpolyposis Type 1) Gene Analysis Full Sequence Analysis


855-339-8127

81296 Msh2 (Muts Homolog 2 Colon Cancer Nonpolyposis Type 1) Gene Analysis Known Familial Variants


Provider Portal

855-339-8127

81297 Msh2 (Muts Homolog 2 Colon Cancer Nonpolyposis Type 1) Gene Analysis DuplicationDeletion Variants


81298 Msh6 (Muts Homolog 6 [E Coli]) Gene Analysis Full Sequence Analysi s 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81299 Msh6 (Muts Homolog 6 [E Coli]) Gene Analysis Known Familial Variants 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81300 Msh6 (Muts Homolog 6 [E Coli]) Gene Analysis DuplicationDeletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81302 Mecp2 (Methyl Cpg Binding Protein 2) (Eg Rett Syndrome) Gene Analysis Full Sequence Analysis


855-339-8127

81303 Mecp2 (Methyl Cpg Binding Protein 2) (Eg Rett Syndrome) Gene Analysis Known Familial Variant


Provider Portal

855-339-8127

81304 Mecp2 (Methyl Cpg Binding Protein 2) (Eg Rett Syndrome) Gene Analysis DuplicationDeletion Variants



81311 NRAS (neuroblastoma RAS viral [v ras] oncogene homolog) (eg colorectal carcinoma)

gene analysis variants in exon 2 (eg codons 12 and 13) and exon 3 (eg codon 61)


Provider Portal

855-339-8127

81313 PCA3KLK3 (prostate cancer antigen 3 non-protein coding kallikrein- related peptidase 3

prostate specific antigen ratio (eg prostate cancer)


855-339-8127

81315 Promyelocytic LeukemiaRetinoic Acid Receptor Alpha (T(1517)) Translocation Analysis

Common Breakpoints QualQuant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

81316 Promyelocytic LeukemiaRetinoic Acid Receptor Alpha (T(1517)) Translocation Analysis Single Breakpoint QualQuant


855-339-8127

81317 Pms2 (Postmeiotic Segregation Increased 2 [S Cerevisiae]) Gene Analysis Full Sequence Analysis


81318 Pms2 (Postmeiotic Segregation Increased 2 [S Cerevisiae]) Gene Analysis Known Familial Variants


855-339-8127

81319 Pms2 (Postmeiotic Segregation Increased 2 [S Cerevisiae]) Gene Ana lysis DuplicationDeletion Variants


855-339-8127

81321 PTEN (Phosphatase And Tensin Homolog) Gene Analysis Full Sequence Analysis 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81322 PTEN (Phosphatase And Tensin Homolog) Gene Analysis Known Familial Variant 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81323 PTEN (Phosphatase And Tensin Homolog) Gene Analysis DuplicationDeletion Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81324 PMP22 (Peripheral Myelin Protein 22) Gene Analysis DuplicationDeletion Analysis 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81325 PMP22 (Peripheral Myelin Protein 22) Gene Analysis Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81326 PMP22 (Peripheral Myelin Protein 22) Gene Analysis Known Familial Variant 05-01-2018 Premera Blue Cross


81327 SEPT9 (Septin9) (eg colorectal cancer) methylation analysis 05-01-2018 Premera Blue Cross


81330 Smpd1(Sphingomyelin Phosphodiesterase 1 Acid Lysosomal) (Eg Niemann-Pick Disease

Type A) Gene Analysis Common Variants


Provider Portal

855-339-8127

81331 SnrpnUbe3A (Small Nuclear Ribonucleoprotein Polypeptide N And Ubiquitin Protein Ligase

E3A) Methylation Analysis


855-339-8127


Date


Review

81332 Serpina1 (Serpin Peptidase Inhibitor Clade A Alpha -1 Antiproteinase Antitrypsin Member

1) Gene AnalysisCommon Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81350 Ugt1A1 (Udp Glucuronosyltransferase 1 Family Polypeptide A1) (Eg Irinotecan Metabolism) Gene AnalysisCommon Variants


81355 Vkorc1 (Vitamin K Epoxide Reductase Complex Subunit 1) (Eg Warfarin Metabolism) Gene

Analysis Common Variants 05-01-2018 Premera Blue Cross


81382 HLA class II typing high resolutionn (ie alleles or allele groups) one locus (eg HLA - DRB1 - DRB345 -DQB1 -DQA1 -DPB1 or -DPA1) each



81400 Molecular Pathology Procedure Level 1 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81401 Molecular Pathology Procedure Level 2 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

81402 Molecular Pathology Procedure Level 3 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81403 Molecular pathology procedure Level 6 (eg analysis of 6-10 exons by DNA sequence

analysis mutation s canning or duplicationdeletion variants of 11-25 exons


Provider Portal

855-339-8127


855-339-8127


855-339-8127


855-339-8127


855-339-8127


Date


Review

81412 Ashkenazi Jewish associated disorders (eg Bloom syndrome Canavan disease cystic fibrosis familial dysautonomia Fanconi anemia group C Gaucher disease Tay-Sachs

disease) genomic sequence analysis panel must include sequencing of at least 9 genes including ASPA BLM CFTR FANCC GBA HEXA IKBKAP MCOLN1 and


Provider Portal

855-339-8127

81413 Cardiac ion channelopathies (eg Brugada syndrome long QT syndrome short QT syndrome catecholaminergic polymorphic ventricular tachycardia) duplicationdeletion

gene analysis panel must include analysis of at least 2 genes including KCNH2 and KCNQ1



81414 Cardiac ion channelopathies (eg Brugada syndrome long QT syndrome short QT syndrome catecholaminergic polymorphic ventricular tachycardia) duplicationdeletion gene analysis panel must include analysis of at least 2 genes including KCNH2 and KCNQ1


855-339-8127

81415 Exome (eg unexplained constitutional or heritable disorder or syndrome) sequence analysis


855-339-8127

81416 Exome (eg unexplained constitutional or heritable disorder or syndrome) sequence

analysis each comparator exome (eg parents siblings) (List separately in addition to code

for primary procedure)


Provider Portal

855-339-8127

81417 Exome (eg unexplained constitutional or heritable disorder or syndrome) re - evaluation of

previously obtained exome sequence (eg updated knowledge or unrelated

conditionsymptom)


855-339-8127

81420 Fetal chromosomal aneuploidy (eg trisomy 21 monosomy X) genomic sequence analysis

panel circulating cell -free fetal DNA in maternal blood must include analysis of chromosome


855-339-8127

81422 Fetal chromosomal microdeletion(s) genomic sequence analysis (eg DiGeorge syndrome

Cri-du-chat syndrome) circulating cell -free fetal DNA in maternal blood


855-339-8127

81432 Hereditary breast cancer-related disorders (eg hereditary breast cancer hereditary ovarian cancer hereditary endometrial cancer) genomic sequence analysis panel must include

sequencing of at least 14 genes including ATM BRCA1 BRCA2 BRIP1 CDH1 MLH1 MSH2 MSH6 NBN PALB2 PTEN RAD51C STK11 and TP53


Provider Portal

855-339-8127

81433 Hereditary breast cancer-related disorders (eg hereditary breast cancer hereditary ovarian

cancer hereditary endometrial cancer) duplicationdeletion analysis panel must include

analyses for BRCA1 BRCA2 MLH1 MSH2 and STK11


Provider Portal

855-339-8127

81435 Hereditary colon cancer syndromes (eg Lynch syndrome familial adenomatosis polyposis)

genomic sequence analysis panel must include analysis of at least 7 genes




Date


Review


genomic sequence analysis panel must include duplicationdeletion gene analysis panel

must include analysis of a t least 8 genes


855-339-8127

81437 Hereditary neuroendocrine tumor disorders (eg medullary thyroid carcinoma parathyroid carcinoma malignant pheochromocytoma or paraganglioma) genomic sequenc e analysis panel must include sequencing of at least 6 genes including MAX SDHB SDHC SDHD TMEM127 and VHL


81438 Hereditary neuroendocrine tumor disorders (eg medullary thyroid carcinoma p arathyroid

carcinoma malignant pheochromocytoma or paraganglioma) duplicationdeletion analysis

panel must include analysis for SDHB SDHC SDHD and VHL


855-339-8127

81439 Inherited cardiomyopathy (eg hypertrophic cardiomyopathy dilated cardiomyopathy arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel must include sequencing of at least 5 genes including DSG2 MYBPC3 MYH7 PKP2 and TTN



81442 Noonan spectrum disorders (eg Noonan syndrome cardio-facio- cutaneous syndrome Costello syndrome LEOPARD syndrome Noonan-like syndrome) genomic sequence analysis panel must include sequencing of at least 12 genes including BRAF CBL HRAS

KRAS MAP2K1 MAP2K2 NRAS PTPN11 RAF1 RIT1 SHOC2 and SOS1


855-339-8127

81490 Autoimmune (rheumatoid arthritis) analysis of 12 biomarkers using immunoas says

utilizing serum prognostic algorithm reported as a disease activity score



81507 Fetal aneuploidy (trisomy 21 18 and 13) DNA sequence analysis of selected regions using

maternal plasma algorithm reported as a risk score for each trisomy


81508 Fetal congenital abnormalities biochemical assays of 2 proteins 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

81509 Fetal congenital abnormalities biochemical assays of 3 proteins 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

81510 Fetal congenital abnormalities biochemical assays of three analytes 05-01-2018 Premera Blue Cross


81511 Fetal congenital abnormalities biochemical assays of 4 analytes 05-01-2018 Premera Blue Cross





Date


Review

81525 Oncology (colon) mRNA gene expression profiling by real -time RT- PCR of 12 genes (7

content and 5 housekeeping) utilizing formalin-fixed paraffin- embedded tissue algorithm

reported as a recurrence score


Provider Portal

855-339-8127

81538 Oncology (lung) mass spectrometric 8-protein signature including amyloid A utilizing

serum prognostic and predictive algorithm reported as good versus poor overall survival


855-339-8127

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 as a

probability of a predicted main cancer type and subtype


81545 Oncology (thyroid) gene expression analysis of 142 genes utilizing fine needle aspirate

algorithm reported as a categorical result (eg benign or suspicious)


855-339-8127

81595 Cardiology (heart transplant) mRNA gene expression profiling by real - time quantitative

PCR of 20 genes (11 content and 9 housekeeping) utilizing subfraction of peripheral blood

algorithm reported as a rejection risk score


Provider Portal

855-339-8127

82106 Alpha-fetoprotein amniotic fluid 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

83020 Hemoglobulin fractionation and quantitation electrophoresis 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

83021 Hemoglobin fractionation and quantitation chromatography 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

86001 Allergen Specific Igg Quantitative or Semiquantitative Each Allergen 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

86003 Allergen Specific IGE each Panel 05-01-2018 Premera Blue Cross


86005 Allergen Specific IGE Multiallergen Screen 05-01-2018 Premera Blue Cross


86813 Tissue TypingHla Typing ABampOr CMul 05-01-2018 Premera Blue Cross



Date


Review

86816 Hla Typing DrDq Single Antigen 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

86817 Hla Typing DrDq Multiple Antigens 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

86821 Hla Typing Lymphocyte Culture Mixed 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

86822 Hla Typing Lymphocyte Culture Prime 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

88235 Tissue culture for non-neoplastic disorders amniotic fluid or chorionic villus cells 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

88240 Cryopreservation freezing and storage of cells each cell line 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

88241 Thawing and expansion of frozen cells each aliquot 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

88245 Chrom An-BreakSyn25cls Ct 51kary 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

88248 Chrom An- BrkSyn100cls Ct202kary 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

88249 Chromosome analysis for breakage syndromes score 100 cells clastogen stress 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

88261 Chrom Analy Ct5 Cells 1 Kary Band 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

88263 ChromAnalct45 Clls-Mosaic 2 Kary Bands 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

88267 Chromosome analysis amniotic fluid or chorionic villus count 15 cells 1 karyotype with banding


855-339-8127


Date


Review

88269 Chromosome analysis in situ for amniotic fluid cells count cells from 612 colonies 1 karyotype with banding


88271 Molecular cytogenetics DNA probe each 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

88273 Molecular cypogenetics chromosomal in situ hybridization analyze 10 -30 cells (eg for microdeletions)


88275 Molecular cytogenetics interphase in situ hybridization analyze 100 -300 cells 05-01-2018 Premera Blue Cross


88280 Chromosomal analysis additional karyotypes each study 05-01-2018 Premera Blue Cross


88291 Cytogenetics and molecular cytogenetics interpretation and report 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

90785 Interactive Diagnostic Interview (interactive complexity add-on code) Premera Blue Cross Provider Portal

855-339-8127

90791 Psychiatric diagnostic evaluation (no medical services) Premera Blue Cross


90792 Psychiatric diagnostic evaluation with medical services Premera Blue Cross Provider Portal

855-339-8127

90832 Psychotherapy 30 min Premera Blue Cross Provider Portal

855-339-8127

90833 30-minute psychotherapy Premera Blue Cross Provider Portal 855-339-8127

90834 Psychotherapy 45 min Optum Behavioral Health Optum provider portal

844-884-1855

90836 45-minute psychotherapy add-on code Optum Behavioral Health

Optum provider portal 844-884-1855

90837 Psychotherapy 60 min Optum Behavioral Health

Optum provider portal

844-884-1855


Date


Review

90838 Interactive individual therapy in IP PHP RTC care setting (60 min with med evaluation amp mgmt)

Optum Behavioral Health


90839 Psychotherapy for crisis first 60 min Optum Behavioral Health


844-884-1855

90840 Crisis code add on for each additional 30 min Optum Behavioral Health


844-884-1855

90845 Psychoanalysis Optum Behavioral Health


844-884-1855

90846 Family psychotherapy without patient present Optum Behavioral Health


844-884-1855

90847 Family psychotherapy with patient present Optum Behavioral Health Optum provider portal

844-884-1855

90849 Multiple family group psychotherapy Optum Behavioral Health Optum provider portal

844-884-1855

90853 Group psychotherapy Optum Behavioral Health


844-884-1855

90865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes (replaces 90835) Optum Behavioral Health


844-884-1855

90867 Therapeutic repetitive transcranial magnetic stimulation treatment planning Optum Behavioral Health Optum provider portal

844-884-1855

90868 Therapeutic repetitive transcranial magnetic stimulation treatment delivery and management



90869 Therapeutic repetitive transcranial magnetic stimulation treatment subsequent motor

threshold redetermination with delivery and management



90870 Outpatient ECT (single seizure) Optum Behavioral Health Optum provider portal

844-884-1855


Date


Review

90871 Outpatient ECT (multiple seizure) Optum Behavioral Health Optum provider portal

844-884-1855

90875 Individual psychophysiological therapy incorporating biofeedback training by any modality

with psychotherapy (20 - 30 min)



844-884-1855



Optum Behavioral Health Optum provider portal

844-884-1855

90880 Hypnotherapy Optum Behavioral Health Optum provider portal

844-884-1855

90882 Environmental intervention for medical management purposes on a psychiatric patients

behalf with agencies employers or institutions



844-884-1855

90885 Psychiatric evaluation of hospital records other psychiatric reports psychometric andor

projective tests and other accumulated data for medical diagnostic purposes


844-884-1855

90887 Interpretation or explanation of results of psychiatric other medical examinations and

procedures or other accumulated data to family or other responsible person or advising

them how to assist patient



90889 Preparation of report of patients psychiatric status history treatment or progress (other

than for legal or consultative purposes) for other physicians agencies or insurance carriers



90899 Unlisted psychiatric service or procedure Optum Behavioral Health Optum provider portal

844-884-1855

90901 Biofeedback training by any modality Optum Behavioral Health Optum provider portal

844-884-1855

90911 Biofeedback training perineal muscles anorectal or urethral sphincter including EMG andor manometry



91065 Breath hydrogen or methane test (eg for detection of lactase deficiency fructose

intolerance bacterial overgrowth or oro-cecal gastrointestinal transit) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

91110 Gastrointestinal Tract Imaging Intraluminal (Eg Capsule Endoscopy) Esophagus Through

Ileum w Phys Interp and Report


855-339-8127

91111 Gastrointestinal Tract Imaging Intraluminal (Eg Capsule Endoscopy) Esophagus with

Physician Interpretation and Report 05-01-2018 Premera Blue Cross


91112 Gastrointestinal Transit And Pressure Measurement Stomach Through Colon Wireless Capsule wInterpretation And Report


92597 Evaluation for use of Voice Prosthetic 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

93228 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to 30

Days Physician Review wReport



93229 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to 30 Days Technical Support


Provider Portal

855-339-8127

93303 Transthoracic echocardiography or congenital cardiac anomalies complete 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

93304 Transthoracic echocardiography or congenital cardiac anomalies follow- up or limited study


866-666-0776

93306 Echocardiography transthoracic real- time with image documentation (2D) includes M- mode recording when performed complete with spectral Doppler echocardiography and with color flow Doppler echocardiography



93307 Transthoracic echocardiography complete without spectral Doppler echocardiography or

color flow Doppler echocardiography




color flow Doppler echocardiography follow-up or limited study


866-666-0776

93312 TEE real-time with image documentation (2-D) (with or without M-mode recording) 01-01-2018 AIM Specialty Health


93313 Placement of transesophageal probe only 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776


Date


Review

93314 Image acquisition interpretation and report only 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776

93315 TEE for congenital cardiac anomalies 01-01-2018 AIM Specialty Health


93316 Placement of transesophageal probe only (congenital cardiac anomalies) 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

93317 Image acquisition interpretation and report only (congenital cardiac anomalies) 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

93320 This code is an add-on code to be used in conjunction with 93303 93304 93312 93314

93315 93317 93350 93351 As such this code does not require separate review




93314 93315 9331 93350 93351 As such this code does not require separate review


AIM Provider Portal

866-666-0776




Provider Portal

855-339-8127

93350 Echocardiography transthoracic during rest and cardiovascular stress test using treadmill

bicycle exercise andor pharmacologically induced stress with interpretation and report


855-339-8127

93351 Echocardiography transthoracic during rest and cardiovascular stress test using treadmill bicycle exercise andor pharmacologically induced stress with interpretation and report including performance of continuous electrocardiographic monitoring with physician

supervision


Provider Portal

855-339-8127

93352 This code is an add-on code to be used in conjunction with 93350 93351 As such this code

does not require separate review



93590 Percutaneous transcatheter closure of paravalvular leak initial occlusion device mitral valve



95805 Mult Sleep Latency recordinginterpretation mult 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

95807 Sleep Study 3 or More Parameters Other Than Staging 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

95808 Polysomnography Sleep Staging with 1 to 3 Additional Parameters 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

95810 Polysomnography Sleep Staging with 4 or More Parameters 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

95811 Polysomnography Sleep Staging With gt3 Addit Parameters W Cpap Attended 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

95951 MonitLateraliz Seiz EEG amp Video 24 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127 96103 Psych testing with interpretation amp report per hour Optum Behavioral Health


96105 Assessment of aphasia Optum Behavioral Health Optum provider portal

844-884-1855

96110 Developmental testing limited with interpretation amp report Optum Behavioral Health Optum provider portal

844-884-1855

96111 Developmental testing extended with interpretation amp report Optum Behavioral Health Optum provider portal

844-884-1855

96116 Neurobehavioral status exam per hr psychologistphysician time patient time and

interpretationrepo rt time (If mbr has behavioral health Dx- please contact Optum for

review)


855-339-8127



96118 Neuropsychological testing per hr psychologistphysician time patient time and

interpretation report time (If mbr has behavioral health Dx- please contact Optum for review)




844-884-1855


Date


Review 96119 Neuropsych testing qualified health care professional interpamp report admin by technician

per hr tech time face-to- face (If mbr has behavioral health Dx- please contact Optum for review)




844-884-1855

96120 Neuropsychological testing administered by a computer w qualified health care professional interpretation and report (If mbr has behavioral health Dx- please contact Optum for review)


855-339-8127



844-884-1855

96130 Psych testing eval services by physician or other qualified health professional incl integration of patient data Interpretation of standardized test results and clinical data clinical decision-making treatment planning and report and interactive feedback to the patient family members(s) or caregiver(s) when performedhellip

01-01-2019 Optum Behavioral Health Optum provider portal

844-884-1855



844-884-1855

96132 Neuropsychological testing evaluation services by physician or other qualified health care professional incl integration of patient data interpretation of standardized test results and clinical data clinical decision -making trmt planning and report and interactive feedback to the patient family member(s) or caregiver(s) when

performedhellip

01-01-2019 Optum Behavioral Health


96133

Neuropsychological testing evaluation services by physician or other qualified health care professional incl integration of patient data interpretation of standardized test results

and clinical data clinical decision -making trmt planning and report and interactive feedback to the patient family member(s) or caregiver(s) when performedhellip


844-884-1855

96136 Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional two or more tests any methodhellip


844-884-1855



844-884-1855

96138 Psychological or neuropsychological test administration and scoring by technician two or more tests any methodhellip




Date


Review




844-884-1855

96146 Psychological or neuropsychological test administration with single automated standardized instrument via electronic platform with automated res ult only


844-884-1855

96150 Health amp behavioral assessment Optum Behavioral Health Optum provider portal

844-884-1855

96151 Health amp behavioral assessment Optum Behavioral Health


844-884-1855


844-884-1855


844-884-1855




844-884-1855

97605 Negative Pressure Wound Therapy Per Session Total Area lt= 50 Sq Cm 05-01-2018 Premera Blue Cross


97606 Negative Pressure Wound Therapy Per Session Total Area gt 50 Sq Cm 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

97607 Negative pressure wound therapy (eg vacuum assisted drainage collection) utilizing disposable non- durable medical equipment including provision of exudate management collection


855-339-8127

97608 Negative pressure wound therapy (eg vacuum assisted drainage collection) utilizing

disposable non- durable medical equipment including provision of exudate management

collection


Provider Portal

855-339-8127

99183 Physician Attendance and Supervision of Hyperbaric Oxygen Therapy Per Session

Note existing code on PA list and review per new medical policy effective 4-1-2020


Provider Portal

855-339-8127


Date


Review

99408 Alcohol andor substance abused structured screening and brief intervention services (15 - 30 min)



844-884-1855

99409 Alcohol andor substance abused structured screening and brief intervention services (30 min or more)


844-884-1855

99510 Home Visit for Individual Family or Marriage Counseling Optum Behavioral Health


844-884-1855

0051T Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy


0095T Removal of total disc arthroplasty anterior approach each additional interspace 05-01-2018 Premera Blue Cross


0169T Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic

agent(s) including computerized stereotactic planning and burr hole(s)


855-339-8127

0182T HDR Electronic Brachytherapy Per Fraction 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


0232T Injection(s) platelet rich plasma any site including image guidance harvesting and preparation

when performed 04-01-2020 Premera Blue Cross

Provider Portal

855-339-8127

0282T Percutaneous Or Open Implantation Of Neurostimulator Electrode Array(s) Subcutaneous For Trial





0284T Revision Or Removal Of Pulse Generator Or Electrodes Including Addition Of New Electrodes When Performed



0295T External electrocardiographic recording for more than 48 hours up to 21 days by

continuous rhythm recording and storage includes recording scanning analysis with

report rev



Date


Review



report rev




continuous rhythm recording and storage recording (includes connection and initial

recording)


Provider Portal

855-339-8127


continuous rhythm recording and storage scanning analysis with report


855-339-8127


continuous rhythm recording and storage review and interpretation


Provider Portal

855-339-8127

0359T Behavior identification assessment by the physician or other qualified health care professional face- to-face with patient and caregiver(s) includes administration of standardized and non-standardized tests detailed behavioral history patient observation and caregiver interview interpretation of test results discussion of findings and


855-339-8127

0360T Observational behavioral follow- up assessment includes physician or other qualified health care professional direction w interpretation and report administered by one technician first 30 minutes of tech time face-to-face wpatient


855-339-8127

0361T Observational behavioral follow- up assessment includes physician or other qualified health care professional direction with interpretation and report administered by one technician each additional 30 minutes of technician time face-to-face with the patient


0362T Exposure behavioral follow-up assessment includes physician or other qualified health care professional direction with interpretation and report administered by physician or other qualified health care professional with the assistance of one or more technicians first 30

minutes of technician(s) time face-to-face with the patient



0363T Exposure behavioral follow-up assessment includes physician or other qualified health care professional direction with interpretation and report administered by physician or other qualified health care professional with the assistance of one or more technicians each additional 30 minutes of technician(s) time face- to-face with the


Provider Portal

855-339-8127

0364T Adaptive behavior treatment by protocol administered by technician face- to-face with

one patient first 30 minutes of technician time


Provider Portal

855-339-8127


Date


Review

0365T Adaptive behavior treatment by protocol administered by technician face-to-face with

one patient each additional 30 minutes of technician time


Provider Portal

855-339-8127

0367T Group adaptive behavior treatment by protocol administered by technician face - to-face

with two or more patients each additional 30 minutes of technician time


855-339-8127

0368T Adaptive behavior treatment with protocol modification administered by physician or other

qualified health care professional with one patient first 30 minutes of patient face-to- face time


855-339-8127


qualified health care professional with one patient each additional 30 minutes of patient

face-to-face time


Provider Portal

855-339-8127

0370T Family adaptive behavior treatment guidance administered by physician or other qualified

health care professional (wo patient present)


855-339-8127

0371T Multiple-family group adaptive behavior treatment guidance administered by physician or

other qualified health care professional (without the patient present)


855-339-8127

0372T Adaptive behavior treatment social skills group administered by physician or other

qualified health care professional face-to- face with multiple patients


855-339-8127

0373T Exposure adaptive behavior treatment with protocol modification requiring two or more

technicians for severe maladaptive behavior(s) first 60 minutes of technicians time face -

to-face with patient


Provider Portal

855-339-8127


technicians for severe maladaptive behavior(s) each additional 30 minutes of technicians

time face-to-face with patient (List separately in addition to code for primary



0438T Transperineal placement of biodegradable material peri - prostatic (via needle) single or

multiple includes image guidance 05-01-2018 Premera Blue Cross


0439T Myocardial contrast perfusion echocardiography at rest or with stress for assessment of

myocardial ischemia or viability (List separately in addition to code for primary procedure)


Provider Portal

855-339-8127


Date


Review

0440T Ablation percutaneous cryoablation includes imaging guidance upper extremity distalperipheral nerve


0441T Ablation percutaneous cryoablation includes imaging guidance lower extremity distalperipheral nerve


Provider Portal

855-339-8127

0442T Ablation percutaneous cryoablation includes imaging guidance nerve plexus or other

truncal nerve (eg brachial plexus pudendal nerve)


Provider Portal

855-339-8127

0443T Real time spectral analysis of prostate tissue by fluorescence spectroscopy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

0444T Initial placement of a drug- eluting ocular insert under one or more eyelids including

fitting training and insertion unilateral or bilateral


Provider Portal

855-339-8127

0445T Subsequent placement of a drug- eluting ocular insert under one or more eyelids including

re-training and removal of existing insert unilateral or bilateral


855-339-8127

0451T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system endovascular approach and programming of sensing and therapeutic parameters complete system (counterpulsation device vascular graft implantable vascular

hemostatic seal mechano-electrical skin interface



0452T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system endovascular approach and programming of sensing and therapeutic parameters aortic counterpulsation device and vascular hemostatic seal


855-339-8127

0453T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular

assist system endovascular approach and programming of sensing and therapeutic parameters mechano-electrical skin interface


855-339-8127

0454T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system endovascular approach and programming of sensing and therapeutic

parameters subcutaneous electrode


855-339-8127

0462T Programming device evaluation (in person) with iterative adjustment of the implantable mechano - electrical skin interface andor external driver to test the function of the device and select optimal permanent programmed values with analysis including review and

report implantable aortic counterpulsation ventricular assist system per day




Date


Review

0463T Interrogation device evaluation (in person) with analysis review and report includes

connection recording and disconnection per patient encounter implantable aortic

counterpulsation ventricular assist system per day


Provider Portal

855-339-8127

0464T Visual evoked potential testing for glaucoma with interpretation and report 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

0497T Ambulatory Event Monitor 08-16-2018 Premera Blue Cross Provider Portal

855-339-8127

0498T Ambulatory Event Monitor 08-16-2018 Premera Blue Cross


0501T Noninvasive estimated coronary fractional flow reserve (FFR) from coronary CTA data using

computation fluid dynamics physiologic simulation software analysis of functional data to

assess severity of coronary artery disease data prep and transmission analysis of fluid

dynamics and simulated maximal coronary hyperemia generation of estimated FFR model

w anatomical data review in comparison w estimated FFR model to reconcile discordant

data interpretation and report


AIM Provider Portal

866-666-0776

0502T Data preparation and transmission 01-01-2018 AIM Specialty Health


0503T Analysis of fluid dynamics and simulated maximal coronary hyperemia and

generation of estimated FFR model



0504T Anatomical data review in comparison with estimated FFR model to reconcile discordant



AIM Provider Portal

866-666-0776


Date


Review A0420 Ambulance waiting time (als or bls) one half (12) hour increments 04-01-2020 Premera Blue Cross

Provider Portal

855-339-8127 A0430 Ambulance service conventional air services transport one way (fixed wing)



A0431 Ambulance service conventional air services transport one way (rotary wing)


855-339-8127 A0435 Fixed wing air mileage per statute mile



A0436 Rotary wing air mileage per statute mile


855-339-8127 A4290 Sacral nerve stimulation test lead each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127 A4575 Topical hyperbaric oxygen disposable 04-01-2020 Premera Blue Cross

Provider Portal

855-339-8127

A7025 High Frequency Chest Wall Oscillation System Vest Replacement For Use 05-01-2018 Premera Blue Cross


A7026 High Frequency Chest Wall Oscillation System Hose Replacement For Use 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

A9272 Wound suction disposable includes dressing all accessories and components any type each


855-339-8127

A9276 Disposable sensor CGM sys 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

A9277 External transmitter CGM 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

A9278 External receiver CGM sys 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

C1767 Generator neurostimulator (implantable) non-rechargeable 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

C1778 Lead neurostimulator (implantable) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

C1816 Receiver andor transmitter neurostimulator (implantable) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

C1883 Adapterextension pacing lead or neurostimulator lead (implantable) 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

C1889 Implantableinsertable device for device intensive procedure not otherwise classified 05-01-2018 Premera Blue Cross


C2614 Probe Percutaneous Lumbar Discectomy 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

C2616 Brachytherapy seed yttrium-90 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

C2698 Brachytherapy source stranded not otherwise specified per source 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

C2699 Brachytherapy source non- stranded not otherwise specified per source 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

C9298 Injection ocriplasmin 0125 mg 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E0193 Powered Air Flotation Bed (Low Air Loss Therapy) 10-21-2019 Premera Blue Cross

Provider Portal

855-339-8127

E0277 Powered pressure-reducing air mattress 10-21-2019 Premera Blue Cross Provider Portal

855-339-8127

E0371 Nonpowered advance pressure reducing overlay for mattress length and width 10-21-2019 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

E0372 Powered air overlay for mattress standard mattress length and width 10-21-2019 Premera Blue Cross Provider Portal

855-339-8127

E0373 Nonpowered advanced pressure reducing mattress 10-21-2019 Premera Blue Cross Provider Portal

855-339-8127

E1390 Oxygen concentrator single delivery port capable of delivering 85 percent or greater

oxygen concentration at the prescribed flow rate


855-339-8127

E0446 Topical oxygen delivery system not otherwise specified



E0466 Home ventilator any type used with non-invasive interface (eg mask chest shell) 08-22-2019 Premera Blue Cross Provider Portal 855-339-8127

E0470 Respiratory assist device bi -level pressure capability without back- up rate feature used

with non- invasive interface eg nasal or facial mask (intermittent assist device with

continuous positive airway pressure device)


Provider Portal

855-339-8127

E0471 Respiratory assist device bi -level pressure capability with back-up rate feature used with

non- invasive interface EG nasal or facial mask (intermittent assist device with continuous

positive pressure device)


Provider Portal

855-339-8127

E0483 High frequency chest wall oscillation air-pulse generator system (includes hoses and vest) each


855-339-8127

E0486 Oral deviceappliance used to reduce upper airway collapsibility adjustable or non - adjustable custom fabricated


E0601 Continuous positive airway pressure (CPAP) device 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E0616 Implantable cardiac event recorder with memory activator and programmer 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E0617 External defibrillator with integrated electrocardiogram analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E0627 Seat lift mechanism incorporated into a combination lift-chair mechanism 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

E0629 Separate seat lift mechanism for use with patient owned furniture non-electric 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E0675 Pneumatic compression device high pressure rapid inflationdeflation cycle 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E0676 Intermittent limb compression device (includes all accessories) not otherwise specified 05-01-2018 Premera Blue Cross


E0747 Osteogenesis stimulator electrical non-invasive other than spinal applications 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

E0748 Osteogenesis stimulator electrical non-invasive spinal applications 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E0749 Osteogenesis stimulator electrical surgically implanted 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E0760 Osteogenesis stimulator low intensity ultrasound non-invasive 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E0765 FDA approved nerve stimulator with replaceable batteries for treatment of nausea and vomiting


855-339-8127

E0784 External ambulatory infusion pump insulin 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E0935 Continuous passive motion exercise device for use on knee only


855-339-8127

E0936 Continuous passive motion exercise device for use other than knee


Provider Portal

855-339-8127

E0988 Manual Wheelchair Accessory Lever-Activated Wheel Drive Pair 05-01-2018 Premera Blue Cross


E1012 Wheelchair accessory addition to power seating system center mount power elevating leg

restplatform complete system any type each 05-01-2018 Premera Blue Cross



Date


Review

E1800 Dynamic adjustable elbow extensionflexion device includes soft interface material 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E1801 SPS elbow device w or wo range of motion adjustment includes all components and accessories


855-339-8127

E1802 Dynamic Adjustable Forearm PronationSupination Device Inc Soft Inter 05-01-2018 Premera Blue Cross


E1805 Dynamic adjustable wrist extensionflexion device includes soft interface material 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

E1806 SPS wrist device w or wo range of motion adjustment includes all components and accessories


855-339-8127

E1810 Dynamic adjustable knee extensionflexion device includes soft interface material 05-01-2018 Premera Blue Cross


E1811 SPS knee device w or wo range of motion adjustment includes all components and accessories


Provider Portal

855-339-8127

E1812 Dynamic knee extensionflexion device with active resistance control 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

E1818 SPS forearm pronationsupination device w or wo range of motion adjustment includes

all components and accessories


855-339-8127

E1820 Replacement soft interface material dynamic adjustable extensionflexion device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E1821 Replacement soft interface materialcuffs for bi -directional static progressive stretch device


855-339-8127

E1825 Dynamic adjustable finger extensionflexion device includes soft interface material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E2359 Power Wheelchair Accessory Group 34 Sealed Lead Acid Battery Each (EG Gel Cell Absorbed Glassmat)




Date


Review

E2378 Power actuator replacement 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E2402 Negative pressure wound therapy electrical pump stationary or portable 05-01-2018 Premera Blue Cross


E2500 Speech generating device digitized speech using pre- recorded messages 8 min or less 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

E2502 Speech generating device digitized speech using pre- recorded messages 8-20 min 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


E2506 Speech generating device digitized speech using pre- recorded messages over 40 min 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

E2508 Speech generating device synthesized speech requiring message formulation by spelling 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

E2510 Speech generating device synthesized speech permitting multiple methods 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

E2511 Speech generating software program for personal computer or personal digital assistant 05-01-2018 Premera Blue Cross


E2512 Accessory for speech generating device mounting system 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

E2599 Accessory for speech generating device not otherwise classified 05-01-2018 Premera Blue Cross


E2622 Adj skin pro wc cus wdlt22in 05-01-2018 Premera Blue Cross


E2623 Adj skin pro wc cus wdgt=22in 05-01-2018 Premera Blue Cross


E2624 Adj skin propos cuslt22in 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

E2625 Adj skin propos wc cusgt=22 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles face to

face one on one each 15 minutes



G0238 Therapeutic procedures to improve respiratory function other than described by G0237

one-on-one face-to-face per 15 minutes (includes monitoring)


855-339-8127

G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles 2 or more individuals (incl monitoring)


G0248 Demonstration prior to initiation of home INR monitoring for patient with either mechanical

heart valve(s) chronic atrial fibrillation or venous thromboembolism who meets Medicare

coverage criteria under the direction of a physician includes face-to-face demonstration

of use and care of the INR monitor obtaining at least one blood sample provision of

instructions for reporting home INR test results and documentation of patients ability to

perform testing and report results


Provider Portal

855-339-8127

G0249 Provision Of Test Materials And Equipment For Home Inr Monitoring To Patient 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

G0250 Physician Review Interpretation And Patient Management Of Home Inr Test 05-01-2018 Premera Blue Cross


G0277 Hyperbaric oxygen under pressure full body chamber per 30 minute interval Note existing code on PA list and review per new medical policy effective 4 -1-2020



G0297 Low dose CT scan (LDCT) for lung cancer screening 01-01-2018 AIM Specialty Health AIM Provider Portal

866-666-0776

G0339 Image-guided robotic linear accelerator-based stereotactic radiosurgery complete course

of therapy in one session or first session of fractionated treatment


866-666-0776

G0340 Image-guided robotic linear accelerator based stereotactic radiosurgery delivery including collimator changes and custom plugging fractionated treatment all lesions per session second through fifth sessions maximum five sessions per course of treatment


866-666-0776

G0341 Percutaneous islet cell trans 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

G0342 Laparoscopy islet cell trans 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

G0343 Laparotomy islet cell transp 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

G0424 Pulmonary rehab w exercise 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (eg as a

result of highly active antiretroviral therapy) 05-01-2018 Premera Blue Cross


G0455 Fecal microbiota prep instil 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

G0500 Moderate sedation services provided by thesame physician or other qualified health care

professional performing a gastrointestinal endoscopic service that sedation supports

requiring the presence of an independent trained observer to assist in the monitoring of

the patients level of consciousness and physiological status initial 15 minutes of intra-

service time patient age 5 years or older (additional time may be reported with 99153 as

appropriate)


Provider Portal

855-339-8127

G6001 Ultrasonic guidance for placement of radiation therapy fields 01-01-2019 AIM Specialty Health AIM Provider Portal

866-666-0776

G6002 Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy


866-666-0776

G6003 Radiation treatment delivery single treatment area single port or parallel opposed ports

simple blocks or no blocks up to 5 MeV


866-666-0776


simple blocks or no blocks 6-10 MeV


866-666-0776




866-666-0776 G6006 Radiation treatment delivery single treatment area single port or parallel opposed ports

simple blocks or no blocks 20 MeV or greater


866-666-0776 G6007 Radiation treatment delivery 2 separate treatment areas 3 or more ports on a single

treatment area use of multiple blocks up to 5 MeV


866-666-0776


Date


Review

G6008 Radiation treatment delivery 2 separate treatment areas 3 or more ports on a single treatment area use of multiple blocks 6-10 MeV


866-666-0776

G6009 Radiation treatment delivery 2 separate treatment areas 3 or more ports on a single

treatment area use of multiple blocks 11-19 MeV


AIM Provider Portal

866-666-0776


treatment area use of multiple blocks 20 MeV or greater


AIM Provider Portal

866-666-0776

G6011 Radiation treatment delivery 3 or more separate treatment areas custom blocking

tangential ports wedges rotational beam compensators electron beam up to 5 MeV 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776


tangential ports wedges rotational beam compensators electron beam 6-10 MeV


AIM Provider Portal

866-666-0776


tangential ports wedges rotational beam compensators electron beam 11-19 MeV 01-01-2019 AIM Specialty Health



tangential ports wedges rotational beam compensators electron beam 20 MeV or

greater


866-666-0776

G6017 Intra-fraction localization and tracking of target or patient motion during delivery of

radiation therapy (eg 3D positional tracking gating 3D surface tracking) each fraction of treatment


AIM Provider Portal

866-666-0776

G9143 Warfarin respon genetic test 05-01-2018 Premera Blue Cross


G9708 Women who had a bilateral mastectomy or who have a hi story of a bilateral mastectomy

or for whom there is evidence of a right and a left unilateral mastectomy


855-339-8127

G9748 Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant


855-339-8127



855-339-8127

H0001 Alcohol andor drug assessment Optum Behavioral Health



Date


Review

H0002 Behavioral health screening to determine eligibility for admission to treatment program Optum Behavioral Health


H0004 Behavioral health counseling and therapy(15 min) Optum Behavioral Health Optum provider portal

844-884-1855

H0005 Alcohol andor drug services group counseling by a clinician Optum Behavioral Health


H0031 Mental health assessment by non- physician per hour (Used as ABA Code) Optum Behavioral Health


H0032 Mental health service plan development by non-physician per hour (Used as ABA Code) Optum Behavioral Health


H0033 Oral medication administration direct observation Optum Behavioral Health


H0046 Mental Health Services Not Otherwise Specified (60 Min) Optum Behavioral Health


H0047 Alcohol andor other drug abuse services not otherwise specified Optum Behavioral Health Optum provider portal

844-884-1855

H2010 Comprehensive Medication Services (15 min) Optum Behavioral Health


844-884-1855

H2011 Crisis Intervention Service (15 min) Optum Behavioral Health Optum provider portal

844-884-1855

H2012 Behavioral Health Day Treatment per hour (Used as ABA Code) Optum Behavioral Health


H2014 Skills Training and Development per 15 minutes (Used as ABA Code) Optum Behavioral Health


H2014 HA

MH Skills Training and Development per 15 min Social Skills Group (multi child amp staff)

childadolescent program per 15 min




Date


Review

H2019 Therapeutic behavioral services per 15 min (Used as ABA Code) Optum Behavioral Health


H2021 In-Home InterventionCommunity- Based Wrap Around Services (Used as ABA Code) Optum Behavioral Health Optum provider portal

844-884-1855

H2027 HA

MH Psychoeducational Services Social Skills Group (multi child amp staff) per 15 min childadolescent program ndash Definition applicable to Pennsylvania (PA) Providers Only (Used as ABA Code)


844-884-1855

Note J Codes for Part B Drugs are listed at the end of the PA list

K0010 Stnd Wt Frame Power Whlchr 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

K0011 Stnd Wt Pwr Whlchr W Control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

K0012 Ltwt Portbl Power Whlchr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

K0013 Custom Power Whlchr Base 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

K0014 Other Power Whlchr Base 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

K0553 Supply allowance for therapeutic continuous glucose monitor (CGM) includes all supplies

and accessories 1 unit of service = 1 months supply


K0554 Receiver (Monitor) dedicated for use with therapeutic continuous glucose monitor system 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

K0606 Automatic external defibrillator with integrated electrocardiogram analysis garment type 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127 K0743 Suction pump home model portable for use on wounds 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

K0744 Absorptive wound dressing for use with suction pump home model portable pad size 16 square inches or less


855-339-8127

K0745 Absorptive wound dressing for use with suction pump home model portable pad size

more than 16 square inches but less than or equal to 48 square inches




greater than 48 square inches


K0800 Power operated vehicle grp 1 standard patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127 K0801 Power operated vehicle grp 1 heavy duty patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross


K0802 Power operated vehicle grp 1 very heavy duty patient weight cap 451 - 600 lbs 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

K0806 Power operated vehicle grp 2 standard patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

K0807 Power operated vehicle grp 2 heavy duty patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross


K0808 Power operated vehicle grp 2 very heavy duty patient weight cap 451 - 600 lbs 05-01-2018 Premera Blue Cross


K0812 Power operated vehicle not otherwise classified 05-01-2018 Premera Blue Cross


K0813 Power wheelchair grp 1 standard portable slingsolid seatback patient weight cap up to and incl 300 lbs


K0814 Power wheelchair grp 1 standard portable captains chair patient weight cap up to and incl 300 lbs


K0815 Power wheelchair grp 1 standard slingsolid seatback patient weight cap up to and incl 300 lbs



K0816 Power wheelchair grp 1 standard captains chair patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review









K0823 Power wheelchair grp 2 stnd captains chair patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127 K0824 Power wheelchair grp 2 heavy duty slingsolid seatback patient weight cap 301 -450 lbs 05-01-2018 Premera Blue Cross


K0825 Power wheelchair grp 2 heavy duty captains chair patient weight cap 301 -450 lbs 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

K0826 Power wheelchair grp 2 very heavy duty slingsolid seatback patient weight cap 451 - 600 lbs



K0827 Power wheelchair grp 2 very heavy duty captains chair patient weight cap 451 -600 lbs 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

K0828 Power wheelchair grp 2 extra heavy duty slingsolid seatback patient weight cap 601 lbs or more



K0829 Power wheelchair grp 2 extra heavy duty captains chair patient weight cap 601 lbs or more



K0835 Power wheelchair grp 2 stnd single power option slingsolid seatback patient weight cap up to and incl 300 lbs


K0836 Power wheelchair grp 2 stnd single power option captains chair patient weight cap up to and incl 300 lbs


K0837 Power wheelchair grp 2 heavy duty single power option slingsolid seatback patient weight cap 301 -450 lbs


K0838 Power wheelchair grp 2 heavy duty single power option captains chair patient weight cap 301 -450 lbs


855-339-8127


Date


Review

K0839 Power wheelchair grp 2 very heavy duty single power option slingsolid seatback

patient weight cap 451 - 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

K0840 Power wheelchair grp 2 extra heavy duty single power option slingsolid seatback

patient weight cap up to and incl 300 lbs


Provider Portal

855-339-8127

K0841 Power wheelchair grp 2 stnd mult power option slingsolid seatback patient weight cap up to and incl 300 lbs


855-339-8127

K0842 Power wheelchair grp 2 stnd mult power option captains chair patient weight cap up to and incl 300 lbs


855-339-8127

K0843 Power wheelchair grp 2 heavy duty mult power option slingsolid seatback patient weight cap 301 -450 lbs


Provider Portal

855-339-8127

K0848 Power wheelchair grp 3 stnd slingsolid seatback patient weight cap up to and incl 300 lbs




855-339-8127

K0850 Power wheelchair grp 3 heavy duty slingsolid seatback patient weight cap 301 -450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

K0851 Power wheelchair grp 3 heavy duty captains chair patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127



855-339-8127

K0853 Power wheelchair grp 3 very heavy duty captains chair patient weight cap 451 -600 lbs 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127





855-339-8127


Date


Review



855-339-8127



K0858 Power wheelchair grp 3 heavy duty single power option slingsolid seatback patient weight cap 301 - 450 lbs


855-339-8127



855-339-8127

K0860 Power wheelchair grp 3 very heavy duty single power option slingsolid seatback patient weight cap 451 -600 lbs


855-339-8127



Provider Portal

855-339-8127



K0863 Power wheelchair grp 3 very heavy duty mult power option slingsolid seatback patient weight cap 451 - 600 lbs


855-339-8127

K0864 Power wheelchair grp 3 extra heavy duty mult power option slingsolid seatback patient

weight cap 601 lbs or more


855-339-8127



Provider Portal

855-339-8127


855-339-8127


Provider Portal

855-339-8127





Date


Review



855-339-8127



855-339-8127

K0879 Power wheelchair grp 4 heavy duty single power option slingsolid seatback patient weight cap 301-450 lbs


Provider Portal

855-339-8127

K0880 Power wheelchair grp 4 very heavy duty single power option slingsolid seatback patient weight 451 - 600 lbs


855-339-8127

K0884 Power wheelchair grp 4 stnd mult power potion slingsolid seatback patient weight cap up to and incl 300 lbs


K0885 Power wheelchair grp 4 stnd mult power option captains chair weight cap up to and incl 300 lbs


855-339-8127

K0886 Power wheelchair grp 4 heavy duty mult power option slingsolid seatback patient weight cap 301- 450 lbs


855-339-8127

K0890 Power wheelchair grp 5 ped single power option slingsolid seatback patient weight cap up to and incl 125 lbs


855-339-8127

K0891 Power wheelchair grp 5 pediatric mult power option slingsolid seatback patient

weight cap up to and incl 125 lbs


Provider Portal

855-339-8127

K0898 Power wheelchair not otherwise classified 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

K0899 Power mobility device not coded by DME PDAC or does not meet criteria 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

L0650 Lumbar-sacral orthosis sagi ttal-coronal control with rigid anterior and posterior

framepanel(s) posterior extends from sacrococcygeal junction to t-9 vertebra lateral

strength provided by rigid lateral framepanel(s) produces intracavitary pressure to reduce

load on intervertebral discs includes straps closures may include padding shoulder

straps pendulous abdomen design prefabricated off-the-shelf




Date


Review

L5610 Addition to lower extremity endoskeletal system above knee hydracadence system 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L5613 Addition to lower extremity endoskeletal system above knee - knee disarticulation 4 bar

linkage with hydraulic swing




linkage with pneumatic swing


L5722 Addition exoskeletal knee-shin system single axis pneumatic swing friction stance phase control


855-339-8127

L5724 Addition exoskeletal knee-shin system single axis fluid swing phase control 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L5726 Addition exoskeletal knee-shin system single axis external joints fluid swing phase control


855-339-8127

L5728 Addition exoskeletal knee-shin system single axis fluid swing and stance phase control 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L5780 Addition exoskeletal knee-shin system single axis pneumatichydra pneumatic swing

phase control


855-339-8127

L5814 Addition endoskeletal knee-shin system polycentric hydraulic swing phase control mechanical stance phase lock



L5816 Addition endoskeletal knee-shin system polycentric mechanical stance phase lock 05-01-2018 Premera Blue Cross


L5822 Addition endoskeletal knee-shin system single axis pneumatic swing friction stance phase control


L5824 Addition endoskeletal knee-shin system single axis fluid swing phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

L5826 Addition endoskeletal knee-shin system single axis hydraulic swing phase control with

miniature high activity frame


Provider Portal

855-339-8127


Date


Review

L5828 Addition endoskeletal knee-shin system single axis fluid swing and stance phase control 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L5830 Addition endoskeletal knee-shin system single axis pneumaticswing phase control 05-01-2018 Premera Blue Cross


L5840 Addition endoskeletal kneeshin system 4-bar linkage or multiaxial pneumatic swing phase control


855-339-8127

L5848 Addition to endoskeletal knee- shin system fluid stance extension dampening feature with or without adjustability


L5856 Addition to lower extremity prosthesis endoskeletal knee- shin system

microprocessor control feature swing and stance



microprocessor control feature swing phase only


855-339-8127

L5858 Addition to lower extremity prosthesis endoskeletal knee shin system microprocessor

control feature stance phase only 05-01-2018 Premera Blue Cross


L5859 Addition to lower extr prosthesis endoskeletal knee-shin sys powered programmable

flexexten assist control incl any type motor(s)


L5961 Addition endoskeletal sys polycentric hip jnt pneum or hydraulic contrl rotation contrl

wwo flex andor ext contrl



L5973 Endoskeletal ankle foot system microprocessor-controlled feature dorsiflexion andor p

lantar flexion control includes power source


855-339-8127 L6026 Transcarpalmetacarpal or partial hand disarticulation prosthesis external power self-

suspended inner socket with removable forearm section electrodes and cables two batteries charger myoelectric control of terminal device excludes terminal device(s)


L6628 Upper extremity addition quick disconnect hook adapter otto bock or equal 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L6629 Upper extremity addition quick disconnect lamination collar with coupling piece otto bock or equal



L6632 Upper extremity addition latex suspension sleeve each 05-01-2018 Premera Blue Cross



Date


Review

L6680 Upper extremity addition test socket wrist disarticulation or below elbow 05-01-2018 Premera Blue Cross


L6687 Upper extremity addition frame type socket below elbow or wrist disarticulation 05-01-2018 Premera Blue Cross


L6715 Terminal device multiple articulating digit includes motor(s) initial issue or replacement 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L6810 Addition to terminal device precision pinch device 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L6880 Electric hand switch or myoelectric controlled independently articulating digits any grasp

pattern or combination of grasp patterns includes motor(s)



L6881 Automatic grasp feature addition to upper limb electric prosthetic terminal device 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L6882 Microprocessor control feature addition to upper limb prosthetic terminal device 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L6890 Addition to upper extremity prosthesis glove for terminal device any material

prefabricated includes fitting and adjustment



L6925 Wrist disarticulation external power self-suspended inner socket removable forearm

shell otto bock or equal electrodes cables two batteries and one charger myoelectronic

control of terminal device


L6935 Below elbow external power self- suspended inner socket removable forearm shell otto

bock or equal electrodes cables two batteries and one charger myoelectronic control of terminal device


L6945 Elbow disarticulation external power molded inner socket removable humeral shell outside locking hinges forearm otto bock or equal electrodes cables two batteries and one charger myoelectronic control of terminal device



L6955 Above elbow external power molded inner socket removable humeral shell internal

locking elbow forearm otto bock or equal electrodes cables two batteries and one

charger myoelectronic control of terminal device


855-339-8127

L6965 Shoulder disarticulation external power molded inner socket removable shoulder shell

shoulder bulkhead humeral section mechanical elbow forearm otto bock or equal

electrodes cables two batteries and one charger myoelectronic control of terminal device


Provider Portal

855-339-8127


Date


Review

L6975 Interscapular-thoracic external power molded inner socket removable shoulder shell




855-339-8127

L7007 Electric hand switch or myoelectric controlled adult 05-01-2018 Premera Blue Cross


L7008 Electric hand switch or myoelectric controlled pediatric 05-01-2018 Premera Blue Cross


L7009 Electric hand switch or myoelectric controlled pediatric 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L7045 Electric hook switch or myoelectric controlled pediatric 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L7180 Electronic elbow microprocessor sequential control of elbow and terminal device 05-01-2018 Premera Blue Cross


L7181 Electronic elbow microprocessor simultaneous control of elbow and terminal device 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L7190 Electronic elbow adolescent variety village or equal myoelectronically controlled 05-01-2018 Premera Blue Cross


L7191 Electronic elbow child variety village or equal myoelectronically controlled 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L7368 Lithium ion battery charger replacement only 05-01-2018 Premera Blue Cross


L7400 Addition to upper extremity prosthesis below elbowwrist disarticulation ultralight

material (titanium carbon fiber or equal)


L7403 Addition to upper extremity prosthesis below elbowwrist disarticulation acrylic material 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127



Date


Review

L8465 Prosthetic shrinker upper limb each 05-01-2018 Premera Blue Cross


L8614 Cochlear device includes all internal and external components 05-01-2018 Premera Blue Cross


L8615 Headsetheadpiece for use with cochlear implant device replacement 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L8616 Microphone for use with cochlear implant device replacement 05-01-2018 Premera Blue Cross


L8617 Transmitting coil for use with cochlear implant device replacement 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L8618 Transmitter cable for use with cochlear implant device replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

L8619 Cochlear implant external speech process or and controller integrated system replacement


L8621 Zinc air battery for use w cochlear implant device replacement each 05-01-2018 Premera Blue Cross


L8622 Alkaline battery for use w cochlear implant device any size replacement 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L8627 Cochlear implant external speech processor component replacement 05-01-2018 Premera Blue Cross


L8628 Cochlear implant external controller component replacement 05-01-2018 Premera Blue Cross


L8629 Transmitting coil and cable integrated for use with cochlear implant device replacement 05-01-2018 Premera Blue Cross


L8680 Implantable neurostimulator electrode each 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L8681 Pt prgrm for implt neurostim 05-01-2018 Premera Blue Cross



Date


Review

L8682 Implt neurostim radiofq rec 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L8683 Radiofq trsmtr for implt neu 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator

receiver for bowel and bladder management replacement



L8685 Implt nrostm pls gen sng rec 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L8686 Implt nrostm pls gen sng non 05-01-2018 Premera Blue Cross


L8687 Implt nrostm pls gen dua rec 05-01-2018 Premera Blue Cross


L8688 Implt nrostm pls gen dua non 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

L8689 External recharging system 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L8690 Auditory osseointegrated device includes all internal and external components 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

L8695 External recharg sys extern 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

M0300 IV Chelation therapy 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q0478 Power adapter combo vad 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q0506 Battery lithium-ion for use with electric or electricpneumatic ventricular assist device replacement only


855-339-8127


Date


Review

Q0507 Misc supply or accessory for use with an external ventricular assist device 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q0509 Misc supply or accessory for use wany implanted ventricular assist device for which pymt

not made under Medicare Part A 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

Q2026 Radiesse Injection 05-01-2018 Premera Blue Cross


Q2028 Sculptra Injection 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

Q4101 Skin substitute Apligraf per square centimeter 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

Q4102 Skin substitute Oasis Wound Matrix per square centimeter 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4105 Skin substitute Integra Dermal Regeneration Templ ate (DRT) per square centimeter 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4106 Skin substitute Dermagraft per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

Q4107 Skin substitute Graftjacket per square centimeter 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4110 Skin substitute Primatrix per square centimeter 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4114 Integra flowable wound matrix injectable 1 cc 05-01-2018 Premera Blue Cross



Date


Review

Q4121 Theraskin 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4124 Oasis ultra tri -layer wound matrix per square centimeter 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4131 Epifix 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

Q4166 Cytal per square centimeter 05-01-2018 Premera Blue Cross


Q4167 Truskin per square centimeter 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

Q4168 Amnioband 1 mg 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4169 Artacent wound per square centimeter 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4170 Cygnus per square centimeter 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

Q4171 Interfyl 1 mg 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4172 Puraply or puraply am per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

Q4173 Palingen or palingen xplus per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

Q4174 Palingen or promatrx 036 mg per 025 cc 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q4175 Miroderm per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

S0317 Disease management program per diem 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

S1040 Cranial Remodeling Orthosis Rigid WSoft Interface Material 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

S2340 Chemodenervation Of Abductor 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

S2341 Chemodenervation of adductor muscle(s) of vocal cord 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

S9473 Pulmonary Rehabilitation Prgm 05-01-2018 Premera Blue Cross


S9485 Crisis intervention mental health services per diem Optum Behavioral Health Optum provider portal

844-884-1855

S9960 Ambulance service conventional air service nonemergency transport one way (fixed wing)


855-339-8127

S9961 Ambulance service conventional air service nonemergency transport one way (rotary wing)


Provider Portal

855-339-8127

PART B DRUGS bull CPT codes with a plus symbol (dagger) are for drugs that have prior authorization overlap with Part D formulary bull CPT codes with a diamond symbol () are for Part B drugs that require Step Therapy



J0129 Orencia 01-01-2019 Premera Blue Cross


J0178 Eylea 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J0179 Beovu 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127

J0180dagger Fabrazyme 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

J0220 Myozyme 01-01-2019 Premera Blue Cross Provider Portal 855-339-8127

J0221dagger Lumizyme 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

J0222 Onpattro 04-01-2020 Premera Blue Cross


J0256 Aralast 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J0256 Aralast NP 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127 J0256 Prolastin-C 01-01-2019 Premera Blue Cross


J0256 Zemaira 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J0257 Glassia 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

J0517 Fasenra 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J0565 Zinplava 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127

J0584 Crysvita 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127

J0585 Botox 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J0586 Dysport 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J0587 Myobloc 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J0588 Xeomin 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J0717 Cimzia 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

J0775 Xiaflex 01-01-2019 Premera Blue Cross


J0897 Prolia 01-01-2019 Premera Blue Cross Provider Portal 855-339-8127

J1300 Soliris 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J1301 Radicava 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

J1303 Ultomiris 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127

J1322 Vimizim 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1325 Flolan Injection 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

J1325 Veletri 01-01-2019 Premera Blue Cross Provider Portal 855-339-8127

J1428 Exondys 51 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1458dagger Naglazyme 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1459dagger Privigen 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1555 Cuvitru 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

J1556dagger Bivigam 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1557dagger Gammaplex 05-01-2018 Premera Blue Cross


J1559 Hizentra 01-01-2019 Premera Blue Cross Provider Portal 855-339-8127

J1561dagger Gammaked 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

J1561dagger Gamunex-C 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1562 Vivaglobin 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J1566dagger Carimune 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1566dagger Gammagard SD 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1568dagger Octagam 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1569dagger Gammagard 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

J1572dagger Flebogamma 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

J1575dagger HyQvia 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J1599 Inj IVIG non-lyophilized NOS 500 mg 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J1602 Simponi Aria 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J1743 Elaprase 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

J1745 Remicade 01-01-2019 Premera Blue Cross Provider Portal 855-339-8127


Date


Review

J1746 Trogarzo 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J1786dagger Cerezyme 05-01-2018 Premera Blue Cross


J1931dagger Aldurazyme 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J2182 Nucala 05-01-2018 Premera Blue Cross Provider Portal 855-339-8127

J2326 Spinraza 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J2357dagger Xolair 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J2503 Macugen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

J2504dagger Adagen 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J2507 Krystexxa 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

J2778 Lucentis 05-01-2018 Premera Blue Cross


J2786 Cinqair 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

J2796 Nplate 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127


Date


Review

J2840 Kanuma 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J2860 Sylvant 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

J3060 Elelyso 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J3111 Evenity 04-01-2020 Premera Blue Cross


J3245 Ilumya 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127

J3262 Actemra 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J3285 Remodulin 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J3304 Zilretta 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127

J3358 Stelara 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

J3380 Entyvio 01-01-2019 Premera Blue Cross Provider Portal 855-339-8127

J3385 VPRIV 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

J3397 Mepsevii 04-01-2020 Premera Blue Cross Provider Portal

855-339-8127


Date


Review

J3398 Luxturna 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J7686 Tyvaso 01-01-2019 Premera Blue Cross Provider Portal 855-339-8127

J9022 Tecentriq 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

J9023 Bavencio 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

J9042 Adcetris 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J9047 Kyprolis 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J9119 Libtayo 04-01-2020 Premera Blue Cross


J9173 Imfinzi 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J9176 Empliciti 05-01-2018 Premera Blue Cross

Provider Portal

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J9205 Onivyde 05-01-2018 Premera Blue Cross Provider Portal

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J9228dagger Yervoy 05-01-2018 Premera Blue Cross

Provider Portal

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J9269 Elzonris 04-01-2020 Premera Blue Cross Provider Portal

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Review

J9271dagger Keytruda 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J9299 Opdivo 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

J9308 Cyramza 05-01-2018 Premera Blue Cross

Provider Portal

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J9311 Rituxan Hycela 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

J9352 Yondelis 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

Q2041 Yescarta 11-01-2018 Premera Blue Cross


Q2042 Kymriah 01-01-2019 Premera Blue Cross

Provider Portal

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Q5103 Inflectra 01-01-2019 Premera Blue Cross Provider Portal

855-339-8127

Q5104 Renflexis 01-01-2019 Premera Blue Cross

Provider Portal

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Discrimination is Against the Law Premera Blue Cross (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Premera does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation Premera provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) Premera provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with Civil Rights Coordinator Complaints and Appeals Premera Blue Cross Medicare Advantage Plans - Complaints amp Appeals PO Box 262527 Plano TX 75026 Phone 888-850-8526 Fax 800-889-1076 TTY 711 Email AppealsDepartmentInquiriesPremeracom You can file a grievance in person or by mail fax or

email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language Assistance ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al

888-850-8526 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 888-850-8526（TTY711） CHUacute Yacute Nếu bạn noacutei T iếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 888-850-8526 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 888-850-8526

(TTY 711) 번으로 전화해 주십시오

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 888-850-8526 (телетайп 711)

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 888-850-8526 (TTY 711)

УВАГА Якщо ви розмовляєте українською мовою ви можете звернутися до безкоштовної служби мовної підтримки Телефонуйте за номером 888-850-8526 (телетайп 711)

បរយតន បររ ើសនជាអន កន យាយ ភាស ខមែ រ បសវាជន យខននកភាសា បរ យម នគតឈន ល គអ ចម នសរាររបរអន ក ច រ ទរស ពទ 888-850-8526 (TTY 711)

注意事項日本語を話される場合無料の言語支援をご利用いただけます888-850-8526（TTY711）

までお電話にてご連絡ください ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር

ይደውሉ 888-850-8526 (መስማት ለተሳናቸው 711)

XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 888-850-8526 (TTY 711)

)711 مكبلاو مصلا فتاه مقر ( 888-850-85 مقرب 26 لصتا ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان

ਧਿ ਆਨ ਧਿ ਓ ਜ ਤ ਸ ਪ ਜਾਬ ਬ ਲਿ ਹ ਤਾ ਭਾਸ਼ ਾ ਧਵਿ ਚ ਸਹ ਾਇਤ ਾ ਸ ਵ ਾ ਤ ਹ ਾਡ

ਲਈ ਮ ਫਤ ਉਪਲਿਬ ਹ 888-850-8526

(TTY 711) ਤ ਕ ਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 888-850-8526 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບ

ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 888-850-8526 (TTY 711)

Premera Blue Cross is an HMO plan with a Medicare contract Enrollment in Premera Blue Cross depends on renewal Y0134_PBC1088_C 028023 (08-12-2019)


Date


Review

11922 TattooColor Defect Ea Add 20 Sq Cm 05-01-2018 Premera Blue Cross Provider Portal

855-339-8127

15002 Surgical Preparation or Creation of Recipient Site TAL 1st 100 Sq Cm or 1 of Body Area of Infants and Children


Provider Portal

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15003 Surgical Preparation or Creation of Recipient Site TAL Ea Addl 100 Sq Cm or Ea Addl 1 of Body Area InfantChild


855-339-8127

15004 Surgical Preparation or Creation of Recipient Site FSEMNEOGHFD 1st 100 Sq Cm

or 1 of Body Area InfantChild


Provider Portal

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15005 Surg Preparation or Creation of Recipient Site FSEMNEOGHFD Ea Addl 100 Sq

Cm or 1 Of Body Area InfantChild


855-339-8127

15271 Skin Subst Graft To Trunk Arms Legs Area Up To 100 Sq Cm First 25 Sq Cm Or Less Wound Surface Area


15272 Skin Subst Graft To Trunk Arms Legs Area Up To 100 Sq Cm Ea Additional 25 Sq Cm Wound Service Area Or Part Thereof



15273 Skin Subst Graft To Trunk Arms Legs Area gt= 100 Sq Cm 1St 100 Sq Cm Or 1 Of Body

Area Of Infants And Children


Provider Portal

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15274 Skin Subst Graft To Trunk Arms Legs Area gt= 100 Sq Cm Ea Addl 100 Sq Cm Or Ea Adl

1 Of Body Area Of InfampChildren


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15277 Skin Subst Graft To FSEMNEOGHFD Area gt= 100 Sq Cm 1St 100 Sq Cm Or 1

Of Body Area Of Infants And Children


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15278 Skin Subst Graft To FSEMNEOGHFD Area gt= 100 Sq Cm Ea Addl 100 Sq Cm Or 1 Of Body Area Of Infants And Children




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