prior authorization code list 2015 - premera blue cross• custom fabricated knee braces • dynamic...

SERVICES REQUIRING PRIOR AUTHORIZATION (LIST SUBJECT TO CHANGE)

An Independent Licensee of the Blue Cross Blue Shield Association Page i of iii 031981 (02-2015) © 2013-2015 PREMERA. All Rights Reserved.

Prior Authorization is required for: Inpatient Facility Admissions • All planned (elective) inpatient hospital

care (surgical, non-surgical, behavioral health and/or substance abuse). Elective admissions must have prior authorization before the admission occurs. For facilities only, notification received within 2 days of admission can serve as prior authorization if the associated service is not listed below.

• Admission to a skilled nursing facility, a long term acute care hospital (LTACH) or a rehabilitation facility

• All residential treatment program admissions

Transplants (inpatient or outpatient)- • Autologous Progenitor Cell Therapy

(stem cell transplants) • Complex Organ Transplants (small

bowel, lung, multi-organ, pancreas, face, limb)

• Transplant donor procedures and services (for all types of transplants)

• No prior authorization needed for cornea, skin, kidney, liver, heart, unless parts of care will involve a clinical trial. (Plan notification of scheduled kidney, liver or heart transplants is recommended to ensure highest level of coverage.)

Elective (non-emergent) air ambulance transport Surgical, Medical, Therapeutic, Diagnostic and Reconstructive Procedures (may be inpatient or outpatient) • Abdominoplasty/Panniculectomy • Blepharoplasty (eyelid surgery) • Bone Anchored and Implantable

Hearing Aids • Breast Surgeries - Selected: (implant

removal, mastectomy for gynecomastia, prophylactic mastectomy, reduction mammoplasty)

• Cardiac Devices, including related services for implantation, if applicable for ventricular assist device for outpatients, implanted and wearable defibrillators, closure devices for septal defects

• Cochlear Implantation

• Corneal Remodeling • Cosmetic or reconstructive surgery

usually done to change appearance (such as face lifts, brow lifts, cervicoplasty, collagen implants, chemical peels/abrasions, abdominoplasty, liposuction, body contouring surgery (skin fold or fat removal from torso or extremity), nose or ear remodeling, scar revision, and others)

• Deep Brain stimulation • Facility Based Sleep Studies

(polysomnography) • Hyperbaric Oxygen Therapy • Hysterectomy • Implantation or Application of Electric

stimulator devices - selected - (gastric, spinal cord, sacral nerve, pelvic floor, implanted bone stimulators, posterior tibial nerve stimulators)

• Knee arthroplasty (replacement) and arthroscopy

• Radiation Therapy –Selected: (stereotactic radiosurgery, gamma knife, proton beam, intensity modulated radiation therapy (IMRT), intraoperative radiation therapy)

• Radiofrequency Ablation of Tumors • Spine surgeries/treatments


An Independent Licensee of the Blue Cross Blue Shield Association Page ii of iii 031981 (02-2015) © 2013-2015 PREMERA. All Rights Reserved.

• Artificial Intervertebral Disc (any level) • Facet Arthroplasty • Vertebroplasty, Kyphoplasty, or

Sacroplasty • Intraspinous traction devices • Radiofrquency treatment of facet joints • Surgery to treat sleep apnea • Upper Gastrointestinal Endoscopy

Varicose Veins and perforator veins– All Procedures

Outpatient Imaging Tests • Positron Emission Tomography (PET

and PET/CT) • Contrast Enhanced Computed

Tomography (CT) Angiography of the heart

• Computed Tomography (CT) Scans • Magnetic Resonance Imaging (MRI) • Magnetic Resonance Angiography

(MRA) • Magnetic Resonance Spectroscopy • Nuclear Cardiology • Echocardiograms

Durable Medical Equipment (DME) and prosthetic devices (See the Clinical Review by Code list for specific codes) Prior Authorization may be required for purchase of DME items including but not limited to: • Bone Growth Stimulators: Electronic

and Ultrasonic • Chest Compression Vests and Devices • Communication or Speech Generation

Devices • Custom fabricated knee braces • Dynamic Splints and home range of

motion and stretching devices • Electrical Stimulation Devices • Home Traction Devices • Hospital Beds and Accessories (no prior

authorization needed for rental of standard bed for hospital to home transitions, for less than three months)

• Jaw Motion Rehab Systems (TMJ) • Lymphedema Pumps • Microprocessor – Controlled Artificial

Limb or Joint • Myoelectric upper arm prosthetic • Power Operated Lifting Devices • Standing frames • Vagal Nerve Stimulators (not TENS)

• Wheelchairs, power operated vehicles, scooters

• No Prior Authorization need for standard manual wheelchair rented for less than three months

• Wheelchair Accessories (beyond basic components)

• Wearable Cardioverter Defibrillator

Rental of DME for home use does not require prior authorization. However rental beyond three months may be reviewed for ongoing medical necessity. Pediatric Orthodontia (Non-Routine) These services are reviewed by Dental Review Staff and should be faxed to 425.918.5956. The Dental Pre-Service Request form can be found here: https://www.premera.com/wa/provider/utilization-review/prospective-review/


An Independent Licensee of the Blue Cross Blue Shield Association Page iii of iii 031981 (02-2015) © 2013-2015 PREMERA. All Rights Reserved.

Drugs Actemra (Tocilizumab) Amevive (Alefacept) Avastin (Bevacizumab) Benlysta (Belimumab) Bexxar (Iodine I131) Cimzia (Certolizumab) Erbitux (Cetuximab) Erythropoietin Stimulating Agent (Epogen, Procrit, Aranesp) Flolan (Epoprostenol Sodium) Growth Factor Receptor Inhibitors

Herceptin (Trastuzumab) Immune Globulin, IV or subcutaneous Lucentis (Ranibizumab) Macugen (Pegaptanib) Mylotarg (Gemtuzumab Ozogamicin) Orencia (Abatacept) Provenge (Sipuleucel-t) Recombinant Human Insulin-like Growth Factor 1 Recombinant Platelet-derived Growth Factor – Wound Healing Remicade (Infliximab)

Remodulin (Treprostinil Sodium) Rituxan (Rituximab) Stelara (Ustekinumab) Synagis (Palivizumab) Vectibix (Panitumumab) Xolair (Omalizumab) Zevalin (Yittrium Y-90)

The following list of drugs is not exhaustive, and only includes those that may be included in your medical benefit. This list does not include any drugs that are subject to the pharmacy prior authorization program. Additionally, the drugs listed below do not necessarily indicate coverage under the member benefits contract, as member contracts differ in their benefits. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply. Specific codes can also be found on the Clinical Review by Code List on the next page. The following medications require prior authorization due to review for medical necessity, and to assure coverage:

Updated 01/16/2015 1 / 140

Code Description Pre-service review requirement Medical Suspense Reason

Medical Records Request

0004M Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score

Pre-Service Review Recommended Investigative History and physical, family history, clinical documentation supporting testing

0006M Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier


0007M Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index


0008M Oncology (breast), mRNA analysis of 58 genes using hybrid capture, on formalin-fixed paraffin-embedded (FFPE) tissue, prognostic algorithm reported as a risk score


0019T Extracorporeal shock wave therapy involving musculoskeletal system

Pre-Service Review Recommended Investigative History and physical, documentation of prior conservative treatment

0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time

Pre-Service Review Recommended Investigative History and Physical, including procedure report

0051T Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report

0052T Replacement or repair of thoracic unit of a total replacement heart system (artificial heart)


0053T Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit


0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)

Pre-Service Review Recommended Medical Necessity History and Physical, and operative report

0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)

Pre-Service Review Recommended Medical Necessity History and Physical, and operative report

00640 Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical, Operative report, and Admitting and Discharge records

Prior Authorization (PA) items require a pre-service review. Note that any planned inpatient stay always requires prior authorization (except maternity-related services).

Clinical Review by Code List - January 2015Pre-service review can be required or recommended. To check the status of a code against a member's plan, use the Prospective Review Tool, then submit the review and check the status of the review online. This list is not exhaustive. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply.

Clinical Review by Code List

Updated 01/16/2015 2 / 140



0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata, volume less than 200 cc of tissue

Pre-Service Review Recommended Investigative History and physical, procedure report

0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue


0073T Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity.

00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum

Pre-Service Review Recommended Medical Necessity Submit anesthesia record, procedure note to include ASA (American Society of Anesthesiologists), physical status classification and BMI. History and Physical indicating risk factors supporting need for monitored anesthesia.

0075T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical and Operative report

0076T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; each additional vessel


00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum

Pre-Service Review Recommended Medical Necessity Submit anesthesia record, procedure note to include ASA (American Society of Anesthesiologists) physical status classification and BMI. History and Physical indicating risk factors supporting need for monitored anesthesia.

0092T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression) cervical; each additional interspace (List separately in addition to code for primary procedure)

Prior Authorization Required Medical Necessity Recent History and Physical, plan of care, and documentation of medical necessity

0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)


0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)


0100T Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy

Pre-Service Review Recommended Investigative History and physical, procedure reporte

0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified; high energy



Updated 01/16/2015 3 / 140



0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle


0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation


0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation


0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia


0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia


0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation


0126T Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment

Pre-Service Review Recommended Investigative Submit History and Physical, documentation of medical necessity

0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace (List separately in addition to code for primary procedure

Prior Authorization Required Investigative Recent History and Physical, plan of care, and documentation of medical necessity

0164T Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace (List separately in addition to code for primary procedure


0165T Revision of total disc arthroplasty (artificial disc),, anterior approach, lumbar, each additional interspace


0169T Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s)

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, Operative report, and plan of care

0171T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level

Prior Authorization Required Investigative History and Physical, Operative report

0172T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure)


0184T Excision of rectal tumor, transanal endoscopic microsurgical approach (ie, TEMS), including muscularis propria (ie, full thickness)

Pre-Service Review Recommended Medical Necessity History and Physical, procedure report

0190T Placement of intraocular radiation source applicator (List separately in addition to primary procedure)

Pre-Service Review Recommended Investigative History and Physical with procedure report


Updated 01/16/2015 4 / 140



0195T Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; single interspace

Prior Authorization Required Investigative History and Physical with procedure report

0196T Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; each additional interspace (List separately in addition to code for primary procedure)

Prior Authorization Required Investigative History and Physical with procedure report

0197T 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

Pre-Service Review Recommended Investigative Submit documentation of medical necessity for use in addition to radiation therapy

01999 Unlisted anesthesia procedure(s) Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include History and Physical with operative report or procedure report

0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles

Prior Authorization Required Investigative Pre Operative Evaluation, History and Physical, and Operative report

0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles

Prior Authorization Required Investigative Pre Operative Evaluation, History and Physical, and Operative report

0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine

Prior Authorization Required Investigative Submit History and Physical, documentation of medical necessity, operative report

0206T Algorithmic analysis, remote, of electrocardiographic-derived data with computer probability assessment, including report

Pre-Service Review Recommended Investigative History and Physical, clinical notes from ordering provider, report results

0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity, procedure report

0232T Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed

Pre-Service Review Recommended Investigative History and Physical, clinical notes from doctor's office related to treatment and condition

0233T Skin advanced glycation endproducts (AGE) measurement by multi-wavelength fluorescent spectroscopy

Pre-Service Review Recommended Cosmetic - Potential Contract Exclusion

Clinical notes from doctor's office related to this condition and treatment

0239T Bioimpedance spectroscopy (BIS), measuring 100 frequencies or greater, direct measurement of extracellular fluid differences between the limbs

Pre-Service Review Recommended Investigative History and Physical, clinical notes from ordering provider, procedure report

0262T Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach

Pre-Service Review Recommended Medical Necessity History and Physical, operative report


Updated 01/16/2015 5 / 140



0263T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest


0264T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest


0265T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow ce


0266T Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed)

Pre-Service Review Recommended Investigative Submit History and physical, operative report and rationale for the device

0267T Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed)

Pre-Service Review Recommended Investigative Submit History and physical, operative report and rationale for the device

0268T Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed)

Pre-Service Review Recommended Investigative Submit History and Physical, operative report and rationale for the device

0269T Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed)


0270T Revision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed)


0271T Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed)


0272T Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report

Pre-Service Review Recommended Investigative Submit History and Physical, procedure report


Updated 01/16/2015 6 / 140



0273T Interrogation device evaluation (in person), carotid sinus baroreflex activation system, the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report; with programming

Pre-Service Review Recommended Investigative Submit History and Physical, procedure report

0275T Percutaneous laminotomy/ laminectomy (intralaminar approach) for decompression of neural elements, with or withoutthe use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar (effective 7/1/11)

Pre-Service Review Recommended Investigative History and Physical, clinical notes from ordering provider, procedure report

0278T Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes)

Pre-Service Review Recommended Investigative Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition

0281T Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation

Pre-Service Review Recommended Investigative History and Physical, procedure report

0282T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of

Pre-Service Review Recommended Medical Necessity History and Physical, procedure report, description of the device

0283T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator


0284T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed


0285T Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed

Pre-Service Review Recommended Investigative History and Physical, procedure report, description of the device

0288T Anoscopy, with delivery of thermal energy to the muscle of the anal canal (eg, for fecal incontinence)

Pre-Service Review Recommended Investigative Submit History and Physical, and procedure report

0291T Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; initial vessel


0292T Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; each additional vessel



Updated 01/16/2015 7 / 140



0302T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; complete system (includes device and electrod

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity, operative report

0303T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; electrode only


0304T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; device only


0305T Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report


0306T Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report


0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary

Pre-Service Review Recommended Investigative History and Physical, operative report, documentation of conservative measures, prior spinal surgery. Review not required for FEP.

0310T Motor function mapping using non-invasive navigated transcranial magnetic stimulation (nTMS) for therapeutic treatment planning, upper and lower extremity


0312T Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming

Pre-Service Review Recommended Investigative History and Physical, and operative report

0313T Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator


0314T Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator


0315T Vagus nerve blocking therapy (morbid obesity); removal of pulse generator


0316T Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator



Updated 01/16/2015 8 / 140



0317T Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed


0319T Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode

Pre-Service Review Recommended Investigative History and Physical. Operative report

0320T Insertion of subcutaneous defibrillator electrode Pre-Service Review Recommended Investigative History and Physical. Operative report0321T Insertion of subcutaneous implantable defibrillator pulse

generator only with existing subcutaneous electrodePre-Service Review Recommended Investigative History and Physical. Operative report

0325T Repositioning of subcutaneous implantable defibrillator electrode and/or pulse generator


0326T Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)


0327T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system


0328T Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis; implantable subcutaneous lead defibrillator system


0330T Tear film imaging, unilateral or bilateral, with interpretation and report

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity

0331T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment;


0332T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT


0334T Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive (indirect visualization), includes obtaining and applying autograft or allograft (structural or morselized), when performed, includes image guidance when performed (eg, CT


0335T Extra-osseous subtalar joint implant for talotarsal stabilization

Pre-Service Review Recommended Investigative HIstory and Physical, documentation of medical necessity, operative report

0340T Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance

Pre-Service Review Recommended Investigative Submit History and Physical, operative report

0342T Therapeutic apheresis with selective HDL delipidation and plasma reinfusion

Pre-Service Review Recommended Medical Necessity HIstory and Physical, documentation of medical necessity


Updated 01/16/2015 9 / 140



0343T Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis

Pre-Service Review Recommended Investigative Submit documentation of medical necessity, operative report

0344T Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis (es) during same session (List separately in addition to code for primary procedure)


0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus


0355T Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report

Pre-Service Review Recommended Investigative History and Physical, clinical notes including any previous diagnostic procedures

0357T Cryopreservation; immature oocyte(s Pre-Service Review Recommended Investigative Pretreatment eval, Records for previous 60 days, Treatment Plan, Diagnostic Test Results

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 recommendations with the primary guardian(s)/caregiver(s), and preparation of report

Pre-Service Review Recommended Medical Necessity Submit chart notes for actual services billed, diagnosis verification and provider state licensure or BCBA certification

0364T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time


0365T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time (List separately in addition to code for primary procedure)


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


0369T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure)


0370T Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)


0372T Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients



Updated 01/16/2015 10 / 140



0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels

Pre-Service Review Recommended Investigative Submit History and Physical, documentation of medical necessity, operative report

0410 Respiratory Care Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status, if homebased. Include plan of care

0421 Physical Therapy Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status, if homebased. Include plan of care

0431 Occupational Therapy Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care

0441 Speech Therapy Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care

0551 Skilled Nursing Visit Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care

0561 Medical Social Services Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care

0571 Aide Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care and supervisor credentials

0589 Home Health (HH)-Other Visits-Other Home Health Visits Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care

0903 Behavioral Health Treatments/Services - Play Therapy Pre-Service Review Recommended Medical Necessity Summary of symptoms, functional impairments (e.g., eating/ sleep/ role/ mood disturbance) and description of play therapy utilized

0904 Behavioral Health Treatments/Services -Activity Therapy Pre-Service Review Recommended Medical Necessity Summary of symptoms, functional impairments (e.g., eating/ sleep/ role/ mood disturbance) and description of activity therapy utilized

11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less


Pre Operative Evaluation, History and Physical including functional impairment, and Operative report.

11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm



11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)




Updated 01/16/2015 11 / 140



11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less


Pre Operative Evaluation, History and Physical including functional impairment, and Operative report

11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc



11952 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc



11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc



11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion

Prior Authorization Required Cosmetic - Potential Contract Exclusion

Pre Operative Evaluation, History and Physical including functional impairment and Operative report.

11970 Replacement of tissue expander with permanent prosthesis



11971 Removal of tissue expander(s) without insertion of prosthesis



15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)


15781 Dermabrasion; segmental, face Prior Authorization Required Medical Necessity Recent History and Physical, plan of care, and documentation of medical necessity

15782 Dermabrasion; regional, other than face Prior Authorization Required Medical Necessity Recent History and Physical, plan of care, and documentation of medical necessity

15783 Dermabrasion; superficial, any site (eg, tattoo removal) Prior Authorization Required Medical Necessity Recent History and Physical, plan of care, and documentation of medical necessity

15786 Abrasion; single lesion (eg, keratosis, scar) Prior Authorization Required Cosmetic - Potential Contract Exclusion

Pre Operative Evaluation, History and Physical including functional impairment, and operative report

15787 Abrasion each additional four lesions (addditional code added per LC)



15788 Chemical peel, facial; epidermal Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including specific condition being treated, and Operative report

15789 Chemical peel, facial; dermal Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including specific condition being treated, and Operative report

15792 Chemical peel, nonfacial; epidermal Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including specific condition being treated, and Operative report

15793 Chemical peel, nonfacial; dermal Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including specific condition being treated, and Operative report


Updated 01/16/2015 12 / 140



15819 Cervicoplasty Prior Authorization Required Cosmetic - Potential Contract Exclusion


15820 Blepharoplasty, lower eyelid Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, operative report and photographs of the affected eyes

15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, operative report and photographs of the affected eyes.

15822 Blepharoplasty, upper eyelid Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, operative report and photographs of the affected eyes.

15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, operative report and photographs of the affected eyes.

15824 Rhytidectomy; forehead Prior Authorization Required Cosmetic - Potential Contract Exclusion


15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)



15826 Rhytidectomy; glabellar frown lines Prior Authorization Required Cosmetic - Potential Contract Exclusion


15828 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap



15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap



15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and Operative report

15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh



15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg



15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip



15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock



15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm




Updated 01/16/2015 13 / 140



15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand



15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad



15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area



15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)


15876 Suction assisted lipectomy; head and neck Prior Authorization Required Cosmetic - Potential Contract Exclusion


15877 Suction assisted lipectomy; trunk Prior Authorization Required Cosmetic - Potential Contract Exclusion


15878 Suction assisted lipectomy; upper extremity Prior Authorization Required Cosmetic - Potential Contract Exclusion


15879 Suction assisted lipectomy; lower extremity Prior Authorization Required Cosmetic - Potential Contract Exclusion


15999 Unlisted procedure, excision pressure ulcer Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and Operative report

17107 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm


17108 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm


17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue

Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include History and Physical with operative report or procedure report.

19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical and Operative report.

19300 Mastectomy for gynecomastia Prior Authorization Required Medical Necessity Pre Operative Office Evaluation, Pathology report, Operative report, Age, Medication Records, Length of time condition present


Updated 01/16/2015 14 / 140



19316 Mastopexy Prior Authorization Required Cosmetic - Potential Contract Exclusion

Pre Operative Evaluation, History and Physical including functional impairment and operative report.

19318 Reduction mammaplasty Prior Authorization Required Medical Necessity Pre -Operative evaluation, height/ weight, previous conservative treatment tried, pathology report, operative report, number of grams of tissue removed.

19324 Mammaplasty, augmentation; without prosthetic implant Prior Authorization Required Cosmetic - Potential Contract Exclusion


19325 Mammaplasty, augmentation; with prosthetic implant Prior Authorization Required Cosmetic - Potential Contract Exclusion


19328 Removal of intact mammary implant Prior Authorization Required Cosmetic - Potential Contract Exclusion


19330 Removal of mammary implant material Prior Authorization Required Cosmetic - Potential Contract Exclusion


19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction


Pre Operative evaluation, History and Physical including functional impairment, and operative report.

19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction



19350 Nipple/areola reconstruction Prior Authorization Required Cosmetic - Potential Contract Exclusion


19355 Correction of inverted nipples Prior Authorization Required Cosmetic - Potential Contract Exclusion

Pre Operative evaluation, History and Physical including functional impairment, and operative report

19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion



19366 Breast reconstruction with other technique Prior Authorization Required Cosmetic - Potential Contract Exclusion


19370 Open periprosthetic capsulotomy, breast Prior Authorization Required Cosmetic - Potential Contract Exclusion


19371 Periprosthetic capsulectomy, breast Prior Authorization Required Cosmetic - Potential Contract Exclusion


19380 Revision of reconstructed breast Prior Authorization Required Cosmetic - Potential Contract Exclusion



Updated 01/16/2015 15 / 140



19499 Unlisted procedure breast Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative)

Prior Authorization Required Medical Necessity History and Physical indicating location of fracture, any member comorbidites. If request is for non union of fracture, include date of fracture,serial radiographs detailing any history of healing, documentation of adequacy of immobilization

20975 Electrical stimulation to aid bone healing; invasive (operative)

Prior Authorization Required Medical Necessity History and Physical indicating location of fracture, any member comorbidites. If request is for non union fracture, include date of fracture,serial radiographs detailing history of healing, documentation of adequacy of immobilization.

20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)

Prior Authorization Required Medical Necessity Date of original fracture, History and Physical including comorbidities, fracture location, serial radiographs showing nonhealing and fracture gap

20982 Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance

Prior Authorization Required Medical Necessity History and Physical, procedure report

20983 Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation

Pre-Service Review Recommended Investigative Submit History and Physical, documentation of medical necessity, procedure report

20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures; image-less (List separately in addition to code for primary procedure)


20999 Unlisted procedure, musculoskeletal system, general Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


21010 Arthrotomy, temporomandibular joint Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request diagnosis, prognosis and chart notes including history of non-invasive or non-surgical attempts to treat the TMJ

21050 Condylectomy, temporomandibular joint (separate procedure)

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request diagnosis, prognosis and chart notes including history of non-invasive or non-surgical attempts to treat the TMJ

21060 Meniscectomy, partial or complete, temporomandibular joint (separate procedure)



Updated 01/16/2015 16 / 140



21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)


21085 Impression and custom preparation; oral surgical splint Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Submit chart notes including type of appliance, history of re-occurring TMJ and copy of diagnostic sleep studies

21086 Impression and custom preparation; auricular prosthesis Pre-Service Review Recommended Cosmetic - Potential Contract Exclusion

Fax BA to Dental Review @ 425-918-5956. Submit chart notes including type of appliance, history of re-occurring TMJ and copy of diagnostic sleep studies

21087 Impression and custom preparation; nasal prosthesis Pre-Service Review Recommended Cosmetic - Potential Contract Exclusion


21088 Impression and custom preparation; facial prosthesis Pre-Service Review Recommended Cosmetic - Potential Contract Exclusion


21089 Unlisted maxillofacial prosthetic procedure Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Submit chart notes including type of appliance, history of re-occurring TMJ and copy of diagnostic sleep studies

21116 Injection procedure for temporomandibular joint arthrography

Pre-Service Review Recommended Medical Necessity History and Physical, documentation of medical necessity

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request cephalometric, panoramic films and photos, age and history of orthodontic treatment.

21121 Genioplasty; sliding osteotomy, single piece Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request cephalometric, panoramic films and photos, age and history of orthodontic treatment.

21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)


21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)



Updated 01/16/2015 17 / 140



21125 Augmentation, mandibular body or angle; prosthetic material


21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request cephalometric, panoramic films and photos, age and history of orthodontic treatment

21137 Reduction forehead; contouring only Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity and previous stages of reconsruction if done

21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)

Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity and previous stages of reconsruction if done

21139 Reduction forehead; contouring and setback of anterior frontal sinus wall

Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity and previous stages of reconsruction if done

21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft


21142 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft


21143 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft


21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956.Request cephalometric, panoramic films and photos, age and history of orthodontic treatment.

21146 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)


21147 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)



Updated 01/16/2015 18 / 140



21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)


21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)


21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I


21155 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I


21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I


21160 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I


21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)



21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft


21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)


21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation


21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation


21198 Osteotomy, mandible, segmental; Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request cephalometric, panoramic films and photos, age and history of orthodontic treatment


Updated 01/16/2015 19 / 140



21199 Osteotomy, mandible, segmental; with genioglossus advancement


21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956.Request cephalometric, panoramic films and photos, age and history of orthodontic treatment

21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)


21209 Osteoplasty, facial bones; reduction Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request cephalometric, panoramic films and photos, age and history of orthodontic treatment.

21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)


History and Physical, and Operative report

21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)


21242 Arthroplasty, temporomandibular joint, with allograft Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request diagnosis, prognosis and chart notes including history of non-invasive or non-surgical attempts to treat the TMJ

21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement


21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)


21270 Malar augmentation, prosthetic material Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956.Request cephalometric, panoramic films and photos, age and history of orthodontic treatment.

21280 Medial canthopexy (separate procedure) Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity and visual field

21282 Lateral canthopexy Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity and visual field

21295 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach

Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity, procedure report


Updated 01/16/2015 20 / 140



21296 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach

Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity, procedure report

21299 Unlisted craniofacial and maxillofacial procedure Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report. Dental review recommended.

21480 Closed treatment of temporomandibular dislocation; initial or subsequent


21485 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent


21490 Open treatment of temporomandibular dislocation Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request diagnosis, prognosis and chart notes including history of non-invasive or non-surgical attempts to treat the TMJ

21499 Unlisted musculoskeletal procedure, head Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


21899 Unlisted procedure, neck or thorax Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


22505 Manipulation of spine requiring anesthesia, any region Pre-Service Review Recommended Medical Necessity Recent History and Physical, plan of care, and documentation of medical necessity

22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral


22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative

22513 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic



Updated 01/16/2015 21 / 140



22514 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar


22515 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure


22520 Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report

22521 Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; lumbar


22522 Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)


22523 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including date of original injury, and Operative report

22524 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); lumbar


22525 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); each additional thoracic or lum


22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level


22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)


22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity including operative report. Review not required for FEP.


Updated 01/16/2015 22 / 140



22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report.

22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)


22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2


22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar


22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)


22586 Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

Pre-Service Review Recommended Investigative History and Physical, operative report, documentation of medical necessity. Review not required for FEP.

22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity including operative report. No review required for FEP

22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar


22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

Prior Authorization Required Medical Necessity History and Physical, operative report, documentation of conservative measures. Review not required for FEP.

22634 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspa

Prior Authorization Required Medical Necessity History and Physical, operative report, documentation of conservative measures. Review not required for FEP.

22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments


22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments



Updated 01/16/2015 23 / 140



22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments


22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments


22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments


22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments


22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical


22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

Prior Authorization Required Investigative Recent History and Physical, plan of care, and documentation of medical necessity.

22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)


22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical


22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar


22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical


22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar


22899 Unlisted procedure, spine Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


22999 Unlisted procedure, abdomen, musculoskeletal system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 24 / 140



23929 Unlisted procedure, shoulder Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


24999 Unlisted procedure, humerus or elbow Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


25999 Unlisted procedure, forearm or wrist Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


26989 Unlisted procedure, hands or fingers Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device


27280 Arthrodesis, sacroiliac joint (including obtaining graft) Pre-Service Review Recommended Investigative Submit HIstory and Physical, medical necessity documentation

27299 Unlisted procedure, pelvis or hip joint Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) Prior Authorization Required Medical Necessity Effective DOS 2/15/2014 submit History and Physical, pre-operation notes, operative report and all radiology reports. Review not required for FEP.

27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment

Prior Authorization Required Medical Necessity Effective DOS 2/15/2014 submit History and Physical, pre-operation notes, operative report and all radiology reports. Review not required for FEP.

27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty

Prior Authorization Required Medical Necessity Effective DOS 2/15/2014 submit History and Physical, pre-operation notes, operative report and all radiology reports. No review for FEP.

27486 Revision of total knee arthroplasty, with or without allograft; 1 component


27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component


27599 Unlisted procedure femur or knee Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 25 / 140



27899 Unlisted procedure, leg or ankle Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


28344 Reconstruction, toe(s); polydactyly Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity, operative report

28890 Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia


28899 Unlisted procedure, foot or toes Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


29799 Unlisted procedure, casting or strapping Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include History and Physical with operative procedure report

29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)


29804 Arthroscopy, temporomandibular joint, surgical Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request diagnosis, prognosis and chart notes including history of non-invasive or non-surgical attempts to treat the TMJ

29868 Arthroscopy, knee, surgical; meniscal transplantation, medial or lateral

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report.

29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity including procedure report. No review required for FEP. No review needed for member under age 18.

29871 Arthroscopy, knee, surgical; for infection, lavage and drainage

Prior Authorization Required Medical Necessity Submit History and Physical, medical necessity documentation including operative report. No review required for FEP. No review needed for member under age 18.

29873 Arthroscopy, knee, surgical; with lateral release Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity including procedure report. No review required for FEP. No review needed for member under age 18.

29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)


29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)



Updated 01/16/2015 26 / 140



29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)


29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)


29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture


29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving)


29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving)


29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity including procedure report. Review not required for FEP. No review needed for member under age 18.

29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)


29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)


29999 Unlisted procedure Arthroscopy Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip


30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip


30420 Rhinoplasty, primary; including major septal repair Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and Operative report

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)



Updated 01/16/2015 27 / 140



30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)


30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)


30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)



30620 Septal or other intranasal dermatoplasty (does not include obtaining graft)



30999 Unlisted procedure, nose Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa

Pre-Service Review Recommended Investigative Pre Operative Evaluation, History and Physical, and Operative report.

31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)


31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)


31299 Unlisted procedure, accessory sinuses Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


31599 Unlisted procedure, larynx Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


31627 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, image-guided navigation (List separately in addition to code for primary procedure[s])

Pre-Service Review Recommended Investigative Pre Operative Evaluation, History and Physical and Operative report

31647 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe


31648 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), initial lobe


31649 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), each additional lobe (List separately in addition to code for primary procedure)



Updated 01/16/2015 28 / 140



31651 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), each additional lobe (List separately in addition to code


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

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity and procedure report

31661 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity and procedure report

31899 Unlisted procedure, trachea, bronchi Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


32701 Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment

Pre-Service Review Recommended Medical Necessity History and Physical, including tumor size and prior treatment

32850 Donor pneumonectomy(s) (including cold preservation), from cadaver

Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

32851 Lung transplant, single; without cardiopulmonary bypass Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

32852 Lung transplant, single; with cardiopulmonary bypass Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

32853 Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass


32854 Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass

Pre-Service Review Recommended Transplant If transplant approval on record: Date of tranplant.If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

32855 Backbench standard preparation of cadaver donor lung allograft prior to transplantation


32856 Bilateral - Backbench standard preparation of cadaver donor lung allograft prior to



Updated 01/16/2015 29 / 140



32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical and Operative report

32999 Unlisted procedure, lungs and pleura Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


33221 Insertion of pacemaker pulse generator only; with existing multiple leads

Prior Authorization Required Medical Necessity History and Physical, plan of care and documentation of medical necessity

33230 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads

Pre-Service Review Recommended Medical Necessity History and Physical, plan of care and documentation of medical necessity

33231 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads

Pre-Service Review Recommended Medical Necessity History and Physical, plan of care and documentation of medical necessity

33270 Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed


33271 Insertion of subcutaneous implantable defibrillator electrode


33273 Repositioning of previously implanted subcutaneous implantable defibrillator electrode


33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach


33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach


33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach


33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach


33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)


33366 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy)

Pre-Service Review Recommended Medical Necessity History and Physical, documentation of medical necessity, operative report

33367 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure)



Updated 01/16/2015 30 / 140



33368 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure


33369 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure)


33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis


33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)


33930 Donor cardiectomy-pneumonectomy (including cold preservation)


33933 Backbench standard preparation of cadaver donor heart/lung allograft


33935 Heart-lung transplant with recipient cardiectomy- pneumonectomy


33940 Donor cardiectomy (including cold preservation) Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

33944 Backbench standard preparation of cadaver donor heart allograft prior to transplantation


33945 Heart transplant, with or without recipient cardiectomy Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

33975 Insertion of ventricular assist device; extracorporeal, single ventricle


33976 Insertion of ventricular assist device; extracorporeal, biventricular


33979 Insertion of ventricular assist device implantable intracorporeal single ventricle



Updated 01/16/2015 31 / 140



33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only

Pre-Service Review Recommended Medical Necessity Preoperative evaluation, History and Physical and operative report

33991 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture


33993 Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion


33999 Unlisted procedure, cardiac surgery Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


35476 Transluminal balloon angioplasty, percutaneous; venous Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity, operative report

36299 Unlisted procedure, vascular injection Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk



36469 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face



36470 Injection of sclerosing solution; single vein Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and Operative report

36471 Injection of sclerosing solution; multiple veins, same leg Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and Operative report

36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency,; first vein treated

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including results of Doppler studies, and Operative report

36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites


36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated



Updated 01/16/2015 32 / 140



36479 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites


36511 Therapeutic apheresis; for white blood cells Prior Authorization Required Transplant Pre Operative Evaluation, History and Physical and Operative report

36512 Therapeutic apheresis; for red blood cells Prior Authorization Required Transplant Pre Operative Evaluation, History and Physical and Operative report

36513 Therapeutic apheresis; for platelets Prior Authorization Required Transplant Pre Operative Evaluation, History and Physical and Operative report

36514 Therapeutic apheresis; for plasma pheresis Pre-Service Review Recommended Medical Necessity History and Physical indicating why plasmapheresis is being done.

36515 Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion


36516 Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion

Pre-Service Review Recommended Medical Necessity History and Physical indicating why extracorporeal selective adsorption being done

36522 Photopheresis, extracorporeal Pre-Service Review Recommended Medical Necessity History and Physical including condition being treated, related diagnostics, and procedure report

37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection


37216 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; without distal embolic protection


37217 Transcatheter placement of an intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation

Pre-Service Review Recommended Medical Necessity History and Physical, documentation of medical necessity, operative report

37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage


37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction


37500 Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)


37501 Unlisted vascular endoscopy procedure Prior Authorization Required Unlisted Code Submit documentation to describe the services. Include History and Physical with operative report or procedure report.

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



Updated 01/16/2015 33 / 140



37718 Ligation, division, and stripping, short saphenous vein Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report

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


37735 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia


37760 Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg

Prior Authorization Required Medical Necessity History and physical, operative report

37761 Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg


37765 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report.

37766 Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report.

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


37785 Ligation, division, and/or excision of varicose vein cluster(s), 1 leg


37788 Penile revascularization, artery, with or without vein graft Pre-Service Review Recommended Impotence - Potential Contract Exclusion

Pre Operative Evaluation, History and Physical and Operative report

37790 Penile venous occlusive procedure Pre-Service Review Recommended Impotence - Potential Contract Exclusion

Pre Operative Evaluation, History and Physical and Operative report

37799 Unlisted procedure, vascular surgery Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


38129 Unlisted laparoscopy procedure, spleen Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


38205 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic


38206 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous

Pre-Service Review Recommended Transplant If transplant approval on record: Date of transplant. If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

38207 Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage



Updated 01/16/2015 34 / 140



38208 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing


38209 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing


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


38212 Transplant preparation of hematopoietic progenitor cells; red blood cell removal


38213 Transplant preparation of hematopoietic progenitor cells; platelet depletion


38214 Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion


38215 Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer


38230 Bone marrow harvesting for transplantation Prior Authorization Required Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

38232 Bone marrow harvesting for transplantation; autologous Prior Authorization Required Transplant History and Physical, procedure report

38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic

Prior Authorization Required Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

38241 Bone marrow or blood-derived peripheral stem cell transplantation; autologous



Updated 01/16/2015 35 / 140



38242 Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions


38589 Unlisted laparoscopy procedure, lymphatic system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


38999 Unlisted procedure, hemic or lymphatic system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


39499 Unlisted procedure, mediastinum Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


39599 Unlisted procedure, diaphragm Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


40500 Vermilionectomy (lip shave), with mucosal advancement Prior Authorization Required Cosmetic - Potential Contract Exclusion

Pre Operative evaluation, History and Physical including functional impairment, and operative report

40702 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956.

40799 Unlisted procedure, lips Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


40899 Unlisted procedure, vestibule of mouth Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


41512 Tongue base suspension, permanent suture technique Prior Authorization Required Investigative History and Physical, Operative report

41530 Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session

Prior Authorization Required Investigative History and Physical, including Sleep study results, results of CPAP trial

41599 Unlisted procedure, tongue, floor of mouth Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Prior Authorization Required Medical Necessity History and Physical, including Sleep study results, results of CPAP trial

42299 Unlisted procedure, palate, uvula Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 36 / 140



42699 Unlisted procedure, salivary glands or ducts Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


42950 Pharyngoplasty (plastic or reconstructive operation on pharynx)

Prior Authorization Required Medical Necessity History and Physical, including Sleep study results, results of CPAP trial

42999 Unlisted procedure, pharynx, adenoids, or tonsils Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


43201 Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance

Pre-Service Review Recommended Medical Necessity History and physical, procedure report

43206 Esophagoscopy, rigid or flexible; with optical endomicroscopy


43212 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, procedure report

43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Prior Authorization Required Medical Necessity Submit History and Physical, procedure report

43236 with directed submucosal injection(s) , any substance (Report 43243 when performing injection sclerosis of esophageal and/or gastric varices)


43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s),


43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

Prior Authorization Required Medical Necessity Submit History and Physical, procedure report.

43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)


43252 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with optical endomicroscopy


43257 Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease


43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, procedure report

43289 Unlisted laparoscopy procedure, esophagus Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 37 / 140



43496 Free jejunum transfer with microvascular anastomosis Pre-Service Review Recommended Obesity - Potential Contract Exclusion

Office evaluation including height and weight, Treatment Plan, Proposed Procedure, Operative report if procedure performed

43499 Unlisted procedure, esophagus Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy

Pre-Service Review Recommended Obesity - Potential Contract Exclusion


43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass small intestine reconstruction to limit absorption



43647 Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum


43648 Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum


43659 Unlisted laparoscopy procedure, stomach Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components



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


Office evaluation including height and weight, Treatment Plan, Proposed Procedure, Operative report if procedure performed.

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



43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only



43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components



43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)



43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty



43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty



43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy




Updated 01/16/2015 38 / 140



43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy



43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption



43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)



43881 Implantation or replacement of gastric neurostimulator electrodes, antrum, open


43882 Revision or removal of gastric neurostimulator electrodes, antrum, open


43886 Gastric restrictive procedure, open; revision of subcutaneous port component only



43887 Gastric restrictive procedure, open; removal of subcutaneous port component only



43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only


Recent History and Physical, plan of care, and documentation of medical necessity

43999 Unlisted procedure, stomach Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


44132 Donor enterectomy (including cold preservation), open; from cadaver donor

Pre-Service Review Recommended Transplant Date of Transplant

44133 Donor enterectomy (including cold preservation), open; partial, from living donor

Pre-Service Review Recommended Transplant Date of Transplant

44135 Intestinal allotransplantation; from cadaver donor Pre-Service Review Recommended Transplant Date of Transplant44136 Intestinal allotransplantation; from living donor Pre-Service Review Recommended Transplant Date of Transplant44137 Removal of transplanted intestinal allograft; complete Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant. If

no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

44238 Unlisted laparoscopy procedure, intestine (except rectum) Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


44715 Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein


44720 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each



Updated 01/16/2015 39 / 140



44721 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each


44799 Unlisted procedure, intestine Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


44899 Unlisted procedure, Meckel's diverticulum and the mesentery



44979 Unlisted laparoscopy procedure, appendix Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


45399 Unlisted procedure, colon Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


45499 Unlisted laparoscopy procedure, rectum Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


45999 Unlisted procedure, rectum Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


46707 Repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS])

Pre-Service Review Recommended Investigative History and physical, operative report, description of plug used

46999 Unlisted procedure, anus Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


47133 Donor hepatectomy (including cold preservation), from cadaver donor


47135 Liver allotransplantation; orthoptic; partial or whole, from cadaver or


47136 Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age



Updated 01/16/2015 40 / 140



47140 Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)


47141 Total left lobectomy (segments II, III, and IV) Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

47142 Total right lobectomy (segments V, VI, VII and VIII) Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

47143 Backbench standard preparation of cadaver donor whole liver graft prior


47144 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, with trisegment split of whole liver graft into 2 partial liver grafts (ie, left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII])


47145 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, with lobe split of whole liver graft into 2 partial liver grafts (ie, left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII])


47146 Backbench reconstruction of cadaver or living donor liver graft prior to transplantation


47147 Arterial anastomosis, each Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

47379 Unlisted laparoscopic procedure, liver Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


47383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation


47399 Unlisted procedure, liver Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 41 / 140



47579 Unlisted laparoscopy procedure, biliary tract Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


47999 Unlisted procedure, biliary tract Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells


48550 Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation


48551 Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft


48552 Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each


48554 Transplantation of pancreatic allograft Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

48999 Unlisted procedure, pancreas Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


49329 Unlisted laparoscopy procedure, abdomen, peritoneum and omentum



49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy



49999 Unlisted procedure, abdomen, peritoneum and omentum Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed

Pre-Service Review Recommended Medical Necessity History and physical, documentation of medical necessity, operative report


Updated 01/16/2015 42 / 140



50300 Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral


50320 Donor nephrectomy (including cold preservation); open, from living donor


50323 Backbench standard preparation of cadaver donor renal allograft prior to transplantation


50325 Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as n


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


50329 Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each


50340 Recipient nephrectomy (separate procedure) Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

50360 Renal allotransplantation; implantation of graft; without recipient


50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy


50542 Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed


50547 Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor



Updated 01/16/2015 43 / 140



50549 Unlisted laparoscopy procedure, renal Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


50592 Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency


50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy

Pre-Service Review Recommended Investigative History and Physical, operative report

50949 Unlisted laparoscopy procedure, ureter Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


53899 Unlisted urinary procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


54125 Amputation of penis; complete Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

54660 Insertion of testicular prosthesis (separate procedure) Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

54699 Unlisted laparoscopy procedure, testis Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


55180 Scrotoplasty; complicated Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

55559 Unlisted laparoscopy procedure, spermatic cord Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


55899 Unlisted procedure, male genital system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


55970 Intersex surgery; male to female Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

55980 Intersex surgery; female to male Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

56625 Vulvectomy simple; complete Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

56800 Plastic repair of introitus Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

56805 Clitoroplasty for intersex state Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

57110 Vaginectomy, complete removal of vaginal wall; Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

57291 Construction of artificial vagina; without graft Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report


Updated 01/16/2015 44 / 140



57292 Construction of artificial vagina; with graft Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

57295 Revision (including removal) of prosthetic vaginal graft; vaginal approach

Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report

57296 Revision (including removal) of prosthetic vaginal graft; open abdominal approach


57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic approach


58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report. Review not required for FEP.

58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch)


58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)


58260 Vaginal hysterectomy, for uterus 250 g or less; Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report. Review not required for FEP.

58262 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)


58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele


58267 Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control


58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele


58275 Vaginal hysterectomy, with total or partial vaginectomy; Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report. Review not required for FEP.

58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele


58290 Vaginal hysterectomy, for uterus greater than 250 grams; Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report. Review not required for FEP.

58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)


58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele



Updated 01/16/2015 45 / 140



58293 Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control


58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele


58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;


58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)


58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;


58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)


58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report. No review for FEP. Review not required for FEP.

58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)


58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams


58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)


58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;


58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, operative report. No review for FEP. Review not required for FEP.

58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;


58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)


58579 Unlisted hysteroscopy procedure, uterus Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 46 / 140



58679 Unlisted laparoscopy procedure, oviduct, ovary Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


58999 Unlisted procedure, female genital system (nonobstetrical)



59898 Unlisted laparoscopy procedure, maternity care and delivery



59899 Unlisted procedure, maternity care and delivery Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


60659 Unlisted procedure, endocrine system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


60699 Unlisted procedure, endocrine system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


61796 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion

Prior Authorization Required Medical Necessity History and Physical, including functional capacity, location, if metastatic, and number of lesions

61797 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure)


61798 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion


61799 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure)


61800 Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)


61850 Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical


61860 Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical



Updated 01/16/2015 47 / 140



61863 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site without use of intraoperative microelectrode recording; first array


61864 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site without use of intraoperative microelectrode recording; each additional array


61867 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site with use of intraoperative microelectrode recording; first array


61868 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site with use of intraoperative microelectrode recording; each additional array


61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array


61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays


62263 Percutaneous lysis of epidural adhesions Pre-Service Review Recommended Investigative History and Physical, Operative report62264 Percutaneous lysis of epidural adhesions1 day Pre-Service Review Recommended Investigative History and Physical, Operative report62287 Decompression procedure, percutaneous, of nucleus

pulposus of intervertebral disc, any method, single or multiple levels, lumbar


63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; lumbar, except for spondylolisthesis

Prior Authorization Required Medical Necessity Effective DOS 5/18/2014 submit History and Physical, prior back surgeries, including minimally invasive, conservative management, MRI/CT, operative report. Review not required for FEP.

63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)


63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar


63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

Prior Authorization Required Medical Necessity Effective DOS 5/18/2014 submit History and Physical, prior back surgeries, including minimally invasive, conservative management, MRI/CT, operative report. No review for FEP.


Updated 01/16/2015 48 / 140



63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar


63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar


63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace


63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar


63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar


63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)

Prior Authorization Required Medical Necessity Effective DOS 5/18/2014 submit History and Physical, prior back surgeries, including minimally invasive, conservative management, MRI/CT, operative report. No review required for FEP.

63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)


63185 Laminectomy with rhizotomy; 1 or 2 segments Prior Authorization Required Medical Necessity Effective DOS 5/18/2014 submit History and Physical, prior back surgeries, including minimally invasive, conservative management, MRI/CT, operative report. Review not required for FEP.

63190 Laminectomy with rhizotomy; more than 2 segments Prior Authorization Required Medical Necessity Effective DOS 5/18/2014 submit History and Physical, prior back surgeries, including minimally invasive, conservative management, MRI/CT, operative report. Review not required for FEP.

63191 Laminectomy with section of spinal accessory nerve Prior Authorization Required Medical Necessity Effective DOS 5/18/2014 submit History and Physical, prior back surgeries, including minimally invasive, conservative management, MRI/CT, operative report. Review not required for FEP.


Updated 01/16/2015 49 / 140



63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar


63272 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar


63620 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion


63621 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)


63650 Percutaneous implantation of neurostimulator electrode array, epidural


63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural


63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed


63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed


63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed


63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed


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


63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver


64553 Percutaneous implantation of neurostimulator electrodes; cranial nerve


64555 Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)

Pre-Service Review Recommended Investigative Recent History and Physical, plan of care, and documentation of medical necessity.

64561 Percutaneous implantation of neurostimulator electrodes sacral nerve (transforaminal placement)


64565 Percutaneous implantation of neurostimulator electrodes; neuromuscular


64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming

Prior Authorization Required Medical Necessity History and Physical, clinical notes from ordering provider, procedure report


Updated 01/16/2015 50 / 140



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

Prior Authorization Required Medical Necessity History and Physical, medical necessity documentation, operative report

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

Prior Authorization Required Medical Necessity History and Physical, medical necessity documentation, procedure report

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

Prior Authorization Required Medical Necessity History and Physical, medical necessity documentation, procedure report

64575 Inserion peripheral nerve stimulator Prior Authorization Required Investigative Recent History and Physical, plan of care, and documentation of medical necessity

64581 Incision of implantation of neurostimulator electrodes sacral nerve (transforaminal placement)


64585 Revision or removal of peripheral neurostimulator electrode array

Prior Authorization Required Medical Necessity History and Physical indicating symptomology, and previous measures tried. Review not required for FEP.

64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling

Prior Authorization Required Investigative History and Physical, procedure report, conservative treatments attempted

64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver

Prior Authorization Required Medical Necessity Historyr and Physical; operative report

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

Prior Authorization Required Medical Necessity History and Physical, operative report, documentation of conservative measures

64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)


64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint


64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)


64999 Unlisted procedure, nervous system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


65756 Keratoplasty (corneal transplant); endothelial Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical and Operative report

65757 Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure)


65760 Keratomileusis Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical and Operative report

65765 Keratophakia Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical and Operative report


Updated 01/16/2015 51 / 140



65767 Epikeratoplasty Prior Authorization Required Medical Necessity History and physical, operative report65770 Keratoprosthesis Prior Authorization Required Medical Necessity History and physical, prosthesis type, operative report

65771 Radial keratotomy Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and Operative report

65772 Corneal relaxing incision for correction of surgically induced astigmatism


65775 Corneal wedge resection for correction of surgically induced astigmatism


66179 Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft


66999 Unlisted procedure of the eye Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


67299 Unlisted procedure, posterior segment Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


67399 Unlisted procedure, ocular muscle Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


67599 Unlisted procedure, orbit Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and operative report including photos

67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)


67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)


67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach


67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach


67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)



Updated 01/16/2015 52 / 140



67908 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)


67909 Reduction of overcorrection of ptosis Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical including functional impairment, and operative report including photos

67912 Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight)

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, documentation of medical necessity and operative report.

67950 Canthoplasty (reconstruction of canthus) Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, documentation of medical necessity and operative report

67961 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to 1/4 of lid margin

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, documentation of medical necessity and operative report

67966 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over 1/4 of lid margin

Prior Authorization Required Medical Necessity Pre Operative Evaluation, History and Physical, documentation of medical necessity and operative report

67999 Unlisted procedure, eyelids Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


68371 Harvesting conjunctival allograft, living donor Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical and Operative report

68399 Unlisted procedure, conjunctiva Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


68899 Unlisted procedure, lacrimal system Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


69300 Otoplasty, protruding ear, with or without size reduction Prior Authorization Required Cosmetic - Potential Contract Exclusion


69399 Unlisted procedure, external ear Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


69710 Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone

Prior Authorization Required Medical Necessity Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level of hearing Impairment.


Updated 01/16/2015 53 / 140



69711 Removal or repair of electromagnetic bone conduction hearing device in temporal bone

Prior Authorization Required Medical Necessity Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level of hearing Impairment.

69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy

Prior Authorization Required Medical Necessity Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level of hearing Impairment

69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy


69717 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy


69718 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy


69799 Unlisted procedure, middle ear Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


69930 Cochlear device implantation, with or without mastoidectomy


69949 Unlisted procedure, inner ear Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


69979 Unlisted procedure, temporal bone, middle fossa approach



70332 Temporomandibular joint arthrography, radiological supervision and interpretation

Pre-Service Review Recommended Medical Necessity History and physical, documentation of medical necessity, procedure report

70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

70450 Computed tomography, head or brain; without contrast material


70460 Computed tomography, head or brain; with contrast material(s)


70470 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections



Updated 01/16/2015 54 / 140



70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material


70481 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)


70482 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections


70486 Computed tomography, maxillofacial area; without contrast material


70487 Computed tomography, maxillofacial area; with contrast material(s)


70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections


70490 Computed tomography, soft tissue neck; without contrast material


70491 Computed tomography, soft tissue neck; with contrast material(s)


70492 Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections


70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing


70498 Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing


70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)


70542 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)


70543 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences


70544 MRA head; w/o contrast Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.


Updated 01/16/2015 55 / 140



70545 MRA head; with contrast Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

70546 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences


70547 Magnetic resonance angiography, neck; without contrast material(s)


70548 Magnetic resonance angiography, neck; with contrast material(s)


70549 Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences


70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material


70552 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)


70553 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences


70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration


70555 Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing


71250 Computed tomography, thorax; without contrast material Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

71260 Computed tomography, thorax; with contrast material(s) Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

71270 Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections


71275 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing



Updated 01/16/2015 56 / 140



71550 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)


71551 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)


71552 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences


71555 MRA chest; with or w/o contrast Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

72125 Computed tomography, cervical spine; without contrast material


72126 Computed tomography, cervical spine; with contrast material


72127 Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections


72128 Computed tomography, thoracic spine; without contrast material


72129 Computed tomography, thoracic spine; with contrast material


72130 Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections


72131 Computed tomography, lumbar spine; without contrast material


72132 Computed tomography, lumbar spine; with contrast material


72133 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections


72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material


72142 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)



Updated 01/16/2015 57 / 140



72146 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material


72147 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)


72148 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material


72149 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)


72156 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical


72157 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic


72158 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar


72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)


72191 Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing


72192 Computed tomography, pelvis; without contrast material Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

72193 Computed tomography, pelvis; with contrast material(s) Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

72194 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections


72195 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)


72196 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)


72197 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences



Updated 01/16/2015 58 / 140



72198 Magnetic resonance angiography, pelvis, with or without contrast material(s)


72291 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance


72292 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance


73200 Computed tomography, upper extremity; without contrast material


73201 Computed tomography, upper extremity; with contrast material(s)


73202 Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections


73206 Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing


73218 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)


73219 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)


73220 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences


73221 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)


73222 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)


73223 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences


73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s)


73700 Computed tomography, lower extremity; without contrast material



Updated 01/16/2015 59 / 140



73701 Computed tomography, lower extremity; with contrast material(s)


73702 Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections


73706 Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing


73718 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)


73719 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)


73720 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences


73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material


73722 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)


73723 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences


73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s)


74150 Computed tomography, abdomen; without contrast material


74160 Computed tomography, abdomen; with contrast material(s)


74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections


74174 Computed tomographic angiography, abdomen and pelvis (New code as of 01/01/2012)


74175 Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing



Updated 01/16/2015 60 / 140



74176 Computed tomography, abdomen and pelvis; without contrast material


74177 Computed tomography, abdomen and pelvis; with contrast material(s)


74178 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions


74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)


74182 Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)


74183 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences


74185 Magnetic resonance angiography, abdomen, with or without contrast material(s)


74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material


74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed


74263 Computed tomographic (CT) colonography, screening, including image postprocessing


75557 Cardiac magnetic resonance imaging for morphology and function without contrast material;


75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging


75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;


75563 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging


75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium



Updated 01/16/2015 61 / 140



75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)


75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function)


75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function)


75635 Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing


75894 Transcatheter embolization Prior Authorization Required Medical Necessity History and Physical, including prior treatment regimens

76077 Dual energy x-ray absorptiometry, bone density study, one or more sites: vertebral fracture assessment

Pre-Service Review Recommended Investigative Recent History and Physical, plan of care, and documentation of medical necessity

76120 Cineradiography/videoradiography, except where specifically included


76125 Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure)


76390 Magnetic resonance spectroscopy Prior Authorization Required Advanced Imaging Online review at www.aimspecialtyhealth.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

76496 Unlisted fluoroscopic procedure (eg, diagnostic, interventional)


Unlisted Code Submit documentation to describe the services. Include Office Notes from ordering physician related to a billed services and radiology report

76497 Unlisted computed tomography procedure (eg, diagnostic interventional)


Unlisted Code Submit documentation to describe the services. Include Office Notes from ordering physician related to a billed services and radiology report.

76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional)



76499 Unlisted diagnostic radiographic procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 62 / 140



76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation


76999 Unlisted ultrasound procedure (eg, diagnostic, interventional)



77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral


77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral


77061 Digital breast tomosynthesis; unilateral Pre-Service Review Recommended Investigative Submit History and Physical, documentation of medical necessity, procedure report

77062 Digital breast tomosynthesis; bilateral Pre-Service Review Recommended Investigative Submit History and Physical, documentation of medical necessity, procedure report

77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)


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


77084 Magnetic resonance (eg, proton) imaging, bone marrow blood supply


77299 Unlisted procedure, therapeutic radiology clinical treatment planning



77301 Intensity modulated radiotherapy plan including dose-volume histograms for target and critical structure partial tolerance specifications


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


77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; multisource Cobalt 60 based or more lesions, including image guidance, entire course not to exceed 5 fractions

Prior Authorization Required Medical Necessity History and Physical, including functional capacity, if metastatic, and number of lesions

77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based



Updated 01/16/2015 63 / 140



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

Prior Authorization Required Medical Necessity History and Physical, including functional capacity,location, if metastatic, and number of lesions

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

Prior Authorization Required Medical Necessity Submit History and Physical, documentation of medical necessity, procedure report

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


77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services



77418 Intensity modulated treatment delivery single or multiple fields/arcs via narrow spatially and temporally modulated beams (eg binary dynamic MLC) per treatment session


77424 Intraoperative radiation treatment delivery, x-ray, single treatment session

Prior Authorization Required Medical Necessity History and Physical, treatment plan, documentation of medical necessity.

77425 Intraoperative radiation treatment delivery, electrons, single treatment session

Prior Authorization Required Medical Necessity History and Physical, treatment plan, documentation of medical necessity.

77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)


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

Prior Authorization Required Medical Necessity History and Physical, including functional capacity,location, if metastatic, and number of lesions

77469 Intraoperative radiation treatment management Prior Authorization Required Medical Necessity History and Physical, treatment plan, documentation of medical necessity.

77499 Unlisted procedure, therapeutic radiology treatment management



77520 Proton treatment delivery; simple, without compensation Prior Authorization Required Medical Necessity History and Physical, treatment plan.

77522 Proton treatment delivery; simple, with compensation Prior Authorization Required Medical Necessity History and Physical, treatment plan. 77523 Proton treatment delivery; intermediate Prior Authorization Required Medical Necessity History and Physical, treatment plan. 77525 Proton treatment delivery; complex Prior Authorization Required Medical Necessity History and Physical indicating why treatment is being

done. 77600 Hyperthermia, externally generated; superficial (ie,

heating to a depth of 4 cm or less)Pre-Service Review Recommended Medical Necessity History and physical, plan of care.

77605 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm)

Pre-Service Review Recommended Medical Necessity History and Physical, submit documentation of medical necessity.


Updated 01/16/2015 64 / 140



77610 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators


77615 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators


77620 Hyperthermia generated by intracavitary probe(s) Pre-Service Review Recommended Medical Necessity History and Physical, procedure report77799 Unlisted procedure, clinical brachytherapy Pre-Service Review Recommended

where description of service is available, otherwise Retrospective Medical Review Required


78099 Unlisted endocrine procedure, diagnostic nuclear medicine



78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine



78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine



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 (


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); multiple studies, at rest and/or


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 and/or stress (exercise or pharmacologic) an


78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation


78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative



Updated 01/16/2015 65 / 140



78468 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique


78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification


78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing


78473 Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification


78481 Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification


78483 Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/ or pharmacologic), wall motion study plus ejection fraction, with or without quantification


78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress


78492 Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress


78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing


78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine



78607 Brain imaging, tomographic (SPECT) Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity and related procedure report

78608 Brain imaging, positron emission tomography (PET); metabolic evaluation


78609 Brain imaging, positron emission tomography (PET); perfusion evaluation



Updated 01/16/2015 66 / 140



78699 Unlisted nervous system procedure, diagnostic nuclear medicine



78799 Unlisted genitourinary procedure, diagnostic nuclear medicine



78811 Tumor imaging, positron emission tomography (PET); limited area (e.g., leg, chest, head/neck)


78812 Tumor imaging, positron emission tomography (PET); skull base to mid-thigh


78813 Tumor imaging, positron emission tomography (PET); whole body


78814 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization: limited areas (e.g., leg, chest, head/neck)


78815 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization: skull base to mid-thigh


78816 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization: whole body


78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine



79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion


79999 Radiopharmaceutical therapy, unlisted procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


81161 DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed

Pre-Service Review Recommended Medical Necessity History and physical, family history, clinical documentation supporting testing

81200 ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common variants (eg, E285A, Y231X)


81201 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence



Updated 01/16/2015 67 / 140



81202 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants


81203 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants


81210 BRAF (v-raf murine sarcoma viral oncogene homolog B1) (eg, colon cancer), gene analysis, V600E variant

Pre-Service Review Recommended Medical Necessity History and Physical, family history, clinical documentation supporting testing

81211 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/ deletion variants in BRCA1


81212 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants


81213 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants


81214 BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants


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


81217 BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant


81223 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence


81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17)


81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)


81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6)


81228 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants


81229 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities



Updated 01/16/2015 68 / 140



81246 FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836)

Pre-Service Review Recommended Medical Necessity Submit History and Physical, family history, clinical documentation supporting testing

81252 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence

Pre-Service Review Recommended Medical Necessity Submit History and physical, family history, clinical documentation supporting testing

81253 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants


81254 GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S1854)])


81255 HEXA (hexosaminidase A [alpha polypeptide]) (e.g., Tay-Sachs disease) gene analysis, common variants (e.g., 1278insTATC, 1421+1G>C, G269S)


81256 HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D)


81257 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant


81280 Long QT syndrome gene analyses (eg, KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); full sequence analysis


81281 Long QT syndrome gene analyses (eg, KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); known familial sequence variant


81282 Long QT syndrome gene analyses (eg, KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); duplication/deletion variants


81287 MGMT (0-6-methylguanine-DNA methyltransferase) (e.g., glioblastoma multiforme), methylation analysis

Pre-Service Review Recommended Investigative History and Physical, family history, clinical documentation supporting testing

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


81291 MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C)



Updated 01/16/2015 69 / 140



81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis


81293 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants


81294 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants


81295 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis


81296 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants


81297 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants


81298 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis


81299 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants


81300 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants


81302 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis


81303 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant


81304 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants


81313 PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer)


81317 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis



Updated 01/16/2015 70 / 140



81318 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants


81319 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants


81321 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis


81322 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant


81323 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant


81324 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis


81325 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis


81326 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant


81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (e.g., warfarin metabolism), gene analysis, common variants (e.g., -1639/3673)*


81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat


81402 Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants of 1 e


81403 Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons)



Updated 01/16/2015 71 / 140



81404 Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis


81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons)


81406 Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia)


81407 Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform)


81408 Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis)


81410 Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK


81411 Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1


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


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)


81417 Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syndrome)


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 chromosomes 13, 18, and 21


81425 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis



Updated 01/16/2015 72 / 140



81426 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to code for primary procedure)


81427 Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/syndrome)


81430 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1


81431 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes


81435 Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2


81436 Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH


81440 Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP


81460 Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection



Updated 01/16/2015 73 / 140



81465 Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed


81470 X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2


81471 X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2


81479 Unlisted molecular pathology procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the test, records from related office visit, history and physical

81500 Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score

Pre-Service Review Recommended Investigative History and Physical, current treatment regiment

81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin, transferrin and pre-albumin), utilizing serum, algorithm reported as a risk score


81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores


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


81519 Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score


81599 Unlisted multianalyte assay with algorithmic analysis Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the test, records from related office visit, history and physical

82656 Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitive

Pre-Service Review Recommended Medical Necessity History and physical, notes from office visit at which tests were ordered

83015 Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); screen



Updated 01/16/2015 74 / 140



83018 Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each


83698 Lipoprotein-associated phospholipase A2 (Lp-PLA2) Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity

84999 Unlisted chemistry procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include office notes from ordering physician related to this study, test or service.

85999 Unlisted hematology and coagulation procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include Office Notes from ordering physician related to this study, test or service

86152 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood);


86153 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required


86353 Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis

Pre-Service Review Recommended Investigative Recent History and Physical, documentation of medical necessity from ordering provider

86817 HLA typing; DR/DQ, multiple antigens Pre-Service Review Recommended Medical Necessity History and physical, plan of care86825 Human leukocyte antigen (HLA) crossmatch, non-

cytotoxic (eg, using flow cytometry); first serum sample or dilution

Pre-Service Review Recommended Transplant History and physical, plan of care

86826 Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution (List separately in addition to primary procedure)

Pre-Service Review Recommended Transplant History and physical, plan of care

86849 Unlisted immunology procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


86999 Unlisted transfusion medicine procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


87999 Unlisted microbiology procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


88199 Unlisted cytopathology procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required



Updated 01/16/2015 75 / 140



88241 Thawing and expansion of frozen cells, each aliquot Prior Authorization Required Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

88299 Unlisted cytogenetic study Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include Office Notes from ordering physician related to this study, test or service.

88348 Electron microscopy; diagnostic Pre-Service Review Recommended Investigative Recent History and Physical, documentation of medical necessity from ordering provider

88375 Optical endomicroscopic image(s), interpretation and report, real-time or referred, each endoscopic session


88399 Unlisted surgical pathology procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


89160 Meat fibers, feces Pre-Service Review Recommended Investigative Submit documentation to describe the services. Include Office Notes from ordering physician related to this study, test or service

89240 Unlisted miscellaneous pathology test Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include Office Notes from ordering physician related to this study, test or service.

89398 Unlisted reproductive medicine laboratory procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code History and physical, description of service

90283 Immune globulin (IgIV), human, for intravenous use Pre-Service Review Recommended Medical Necessity History and Physical and recent lab work90284 Immune globulin (SCIg), human, for use in subcutaneous

infusions, 100 mg, eachPre-Service Review Recommended Medical Necessity History and Physical and recent lab work

90287 Botulinim antitoxin Pre-Service Review Recommended Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

90288 Botulism Immune Globulin Pre-Service Review Recommended Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each

Prior Authorization Required Medical Necessity Age or gestational age, History of respiratory problems, Current medical treatment, if any risk factors


Updated 01/16/2015 76 / 140



90399 Unlisted immune globulin Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include office notes specifying reason for billed services

90749 Unlisted vaccine/toxoid Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Include office notes specifying reason for billed services

90867 Therapeutic repetitive transcranial magnetic stimulation treatment; planning

Pre-Service Review Recommended Medical Necessity History and Physical, chart notes from ordering physician, treatment plan.

90868 Therapeutic repetitive transcranial magnetic stimulation treatment; delivery and management, per session

Pre-Service Review Recommended Medical Necessity History and Physical, chart notes from ordering physician, treatment plan and results.

90869 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management


90880 Hypnotherapy Pre-Service Review Recommended Medical Necessity History and physiscal, documentation of medical necessity, treatment plan

90899 Unlisted Pyschiatric Services Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services provided along with a summary of symptoms and functional impairments related to that service.

91110 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with physician interpretation and report

Pre-Service Review Recommended Medical Necessity History and Physical or clinical note including any previous diagnostic procedures.

91111 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with physician interpretation and report

Pre-Service Review Recommended Medical Necessity History and Physical or clinical note including any previous diagnostic procedures.

91112 Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report

Pre-Service Review Recommended Investigative History and Physical, chart notes from the ordering physician, test results.

91299 Unlisted diagnostic gastroenterology procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. History and Physical,including description of specific service or procedure rendered

92499 Unlisted eye procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. History and Physical,including description of specific service or procedure rendered

92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech

Pre-Service Review Recommended Medical Necessity History and Physical, Office Notes from ordering Physician for visits related to the billed service and results of testing performed

92609 Therapeutic services for the use of speech-generating device, including programming and modification



Updated 01/16/2015 77 / 140



92700 Unlisted otorhinolaryngological service or procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. History and Physical,including description of specific service or procedure rendered.

92920 Percutaneous transluminal coronary angioplasty; single major coronary artery or branch

Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity, operative report. Review not required for FEP.

92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch


92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch


92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch


92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vesse


92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel


93260 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system


93261 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system


93292 Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; wearable defibrillator system

Pre-Service Review Recommended Medical Necessity Recent History and Physical, plan of care, and documentation of medical necessity


Updated 01/16/2015 78 / 140



93303 Transthoracic echocardiography for congenital cardiac anomalies; complete


93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study


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 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography


93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study


93312 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report


93313 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only


93314 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only


93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report


93316 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only


93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only


93350 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report;



Updated 01/16/2015 79 / 140



93351 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report


93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;


93455 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation


93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization


93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) including intraprocedural injection(s


93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization


93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization


93460 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization


93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization


93580 Percutaneous transcatheter closure of congenital interatrial communication (ie, fonton fenestration, atrial septal defect) with implant

Pre-Service Review Recommended Medical Necessity History and Physical, procedure report including name of trascatheter device used

93644 Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)



Updated 01/16/2015 80 / 140



93702 Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)


93745 Initial set-up and programming by a physician of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository


93799 Unlisted cardiovascular service or procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


93895 Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral


94799 Unlisted pulmonary service or procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


95060 Opthalmic mucus membrane tests Pre-Service Review Recommended Investigative History and Physical, procedure report95199 Unlisted allergy/clinical immunologic service or procedure Pre-Service Review Recommended



95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)

Pre-Service Review Recommended Investigative History and physical, plan of care.

95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist

Prior Authorization Required Medical Necessity Submit History and Physical, medical necessity documentation, procedure report.

95808 Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist


95810 Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist


95811 Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist


95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report


95965 Magnetoencephalography (MEG) recording and analysis for spontaneous brain magnetic activity (eg epileptic cerebral cortex localization)

Pre-Service Review Recommended Medical Necessity History and Physical, including condition being treated


Updated 01/16/2015 81 / 140



95966 Magnetoencephalography (MEG) recording and analysis for evoked magnetic fields single modality (eg sensory motor language or visual cortex localization)


95967 Magnetoencephalogrpahy (MEG) recording and analysis for evoked magnetic fields each additional modality (eg sensory motor language or visual cortex localization)


95970 Electronic analysis of implanted neurostimulator pulse generator system; simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogr

Pre-Service Review Recommended Medical Necessity Test results, notes from related office visit

95971 Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord, or peripheral (ie, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming

Prior Authorization Required Medical Necessity Test results, notes from related office visit

95972 Electronic analysis of implanted neurostimulator pulse generator system; complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour


95973 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements


95974 Electronic analysis of implanted neurostimulator pulse generator system; complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour


95975 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements

Pre-Service Review Recommended Medical Necessity History and Physical or clinical note, including previous treatments tried and percent of body area affected

95978 Electronic analysis of implanted neurostimulator pulse generator system

Pre-Service Review Recommended Medical Necessity History and Physical including comorbidities, previously tried clinical interventions and operative report if any available


Updated 01/16/2015 82 / 140



95979 Electronic analysis of implanted neurostimulator pulse generator system, complex deep brain neurostimulatorpulse generator/transmitter, with initial or subsequent programming; each additional 30 minutes after first hour


95980 Electronic analysis of implanted neurostimulator pulse generator system gastric neurostimulator pulse generator/transmitter; intraoperative, with programming

Pre-Service Review Recommended Medical Necessity History and Physical, interpretation of results

95981 Electronic analysis of implanted neurostimulator pulse generator system gastric neurostimulator pulse generator/transmitter; subsequent, without reprogramming

Pre-Service Review Recommended Medical Necessity History and Physical, interpretation of results

95982 Electronic analysis of implanted neurostimulator pulse generator system gastric neurostimulator pulse generator/transmitter; subsequent, with reprogramming

Pre-Service Review Recommended Medical Necessity History and Physical, interpretation of results, procedure report

95999 Unlisted neurological or neuromuscular diagnostic procedure



96002 Dynamic surface electromyography during walking or other functional activities 1-12-muscles

Pre-Service Review Recommended Medical Necessity History and Physical; office notes including condition being treated.

96446 Chemotherapy administration into the peritoneal cavity via indwelling port or catheter

Pre-Service Review Recommended Medical Necessity Recent History and Physical, plan of care and documentation of medical necessity

96549 Unlisted chemotherapy procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


96999 Unlisted special dermatological service or procedure Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


97039 Unlisted modality (specify type and time if constant attendance)


Unlisted Code Submit documentation to describe the services. Specify procedure performed and treatment plan.

97139 Unlisted therapeutic procedure (specify) Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Specify procedure performed and treatment plan

97755 Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report, each 15 minutes



Updated 01/16/2015 83 / 140



97799 Unlisted physical medicine/rehabilitation service or procedure


Unlisted Code Submit documentation to describe the services. Specify procedure performed and treatment plan.

99082 Unusual travel (eg, transportation and escort of patient) Pre-Service Review Recommended Medical Necessity Recent History and Physical if applicable and Letter of Medical Necessity documenting the need for the requested service

99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session

Prior Authorization Required Medical Necessity History and Physical with medical necessity, treatment plan, treatments tried and failed and procedure report

99199 Unlisted special service or report Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the services. Specify procedure performed and treatment plan

99500 Home visit for prenatal monitoring and assessment to include fetal heart rate non-stress test uterine monitoring and gestational diabetes monitoring

Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

99501 Home visit for postnatal assessment and follow up care Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

99502 Home visit for newborn care and assessment Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

99503 Home visit for respiratory therapy care (eg bronchodilator oxygen therapy respiratory assessment apnea evaluation)


99504 Home visit for patients receiving mechanical ventilation Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

99505 Home visits for stoma care and maintenance including colostomy and cystostomy


99506 Home visit for intramuscluar injections Pre-Service Review Recommended Medical Necessity History and physical, notes from home visit99507 Home visit for care and maintenance for catheter(s) (eg

urinary drainage and enteral)Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for

each discipline providing treatment99508 Home visit for polysomnography and sleep studies Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for

each discipline providing treatment99509 Home visit for assistance with activities of daily living and

personal carePre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for

each discipline providing treatment99510 Home visit for individual family or marriage counseling Pre-Service Review Recommended Medical Necessity Recent History and Physical, plan of care, and

documentation of medical necessity99511 Home visit for fecal impaction management and enema

administrationPre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for

each discipline providing treatment99512 Home visit for hemodialysis per diem Pre-Service Review Recommended Medical Necessity Recent History and Physical, plan of care, and

documentation of medical necessity99600 Unlisted home visit service or procedure Pre-Service Review Recommended


Unlisted Code Submit documentation to describe the services. Include chart notes for each home visit, documentation of home bound status and treatment plan

A0140 Nonemergency transportation and air travel (private or commercial) intra- or interstate

Pre-Service Review Recommended Medical Necessity Recent History and Physical if applicable and Letter of Medical Necessity documenting the need for the requested service


Updated 01/16/2015 84 / 140



A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)

Pre-Service Review Recommended Medical Necessity Submit progress notes for last 24 hours prior to transport, physician order including medical records supporting rationale for transport

A0428 Ambulance service, basic life support, nonemergency transport, (BLS)

Pre-Service Review Recommended Medical Necessity Submit progress notes for last 24 hours prior to transport, physician order including medical records supporting rationale for transport

A0430 Ambulance service, conventional air services, transport, one way (fixed wing)

Pre-Service Review Recommended Medical Necessity Submit progress notes for last 24 hours prior to transport, physician order including medical records supporting rationale for transport.

A0431 Ambulance service, conventional air services, transport, one way (rotary wing)

Pre-Service Review Recommended Medical Necessity Submit progress notes for last 24 hours prior to transport, physician order including medical records supporting rationale for transport.

A0999 Unlisted ambulance service Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit description of the services provided and transport record.

A4290 Sacral nerve stimulation test lead, each Pre-Service Review Recommended Medical Necessity History and Physical, procedure reportA4555 Electrode/transducer for use with electrical stimulation

device used for cancer treatment, replacement onlyPre-Service Review Recommended Investigative Submit History and Physical, documentation of

medical necessity

A4575 Topical hyperbaric oxygen chamber, disposable Pre-Service Review Recommended Investigative History and Physical, clinical notes including specific condition being treated

A4633 Replacement bulb/lamp for ultraviolet light therapy system, each

Pre-Service Review Recommended Medical Necessity History and Physical or clinical notees including specific condition being treated

A4638 Replacement battery for patient-owned ear pulse generator, each

Pre-Service Review Recommended Investigative History and physical, documentation for condition being treated

A4639 Replacement pad for infrared heating pad system, each Pre-Service Review Recommended Investigative History and physical, documentation for condition being treated

A7025 High frequency chest wall oscillation system vest, replacement for use with patient-owned equipment, each

Prior Authorization Required Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition

A7026 High frequency chest wall oscillation system hose, replacement for use with patient-owned equipment, each


A9276 Continuous Monitoring of Glucose in the Interstitial Fluid Pre-Service Review Recommended Medical Necessity History and Physical or clinical notes, including anticipated length of use



A9507 Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries


A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries

Prior Authorization Required Medical Necessity History and Physical, plan of care and procedure report

A9545 Iodine I-131 tositumomab, therapeutic, per treatment dose Prior Authorization Required Medical Necessity History and Physical, plan of care and procedure report

A9582 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity and related procedure report


Updated 01/16/2015 85 / 140



A9584 Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity and related procedure report.

A9586 Florbetapir F18, diagnostic, per study dose, up to 10 millicuries

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity and related procedure report

A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code


Unlisted Code Submit documentation to describe the services. Include physician order and documentation of medical necessity

A9999 Miscellaneous DME supply or accessory, not otherwise specified


Unlisted Code Submit the description of equipment provided, letter of medical necessity including current medical condition and mobility status.

C1818 Integrated keratoprosthesis Pre-Service Review Recommended Medical Necessity Letter of medical necessity supporting need for the keratoprosthesis

D7880 Occlusal Orthotic Device, by report Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Doc Req - Type of appliance, diagnosis, prognosis, and chart notes including a narrative of therapeutic proc and hx of re-occurring TMJ dysfunction.

E0171 Commode chair with integrated seat lift mechanism, nonelectric, any type

Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status

E0193 Powered air flotation bed (low air loss therapy) Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status

E0194 Air fluidized bed Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status

E0218 Water circulating cold pad with pump Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition. Include invoice of cost for item.

E0221 Infrared heating pad system Pre-Service Review Recommended Investigative Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition

E0236 Pump for water circulating pad Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition. Include invoice of cost for item.

E0248 Transfer bench, heavy-duty, for tub or toilet with or without commode opening

Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition


Updated 01/16/2015 86 / 140



E0250 Hospital bed, fixed height, with any type side rails, with mattress

Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of special bed; including mobility status

E0251 Hospital bed, fixed height, with any type side rails, without mattress


E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress


E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress


E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress

Prior Authorization Required Medical Necessity Letter of medical necessity including mobility status and anticipated length of time patient will require the equipment.

E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress


E0265 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress


E0266 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress


E0270 Hospital bed, institutional type includes: oscillating ,circulating, and stryker frame, with mattress


E0277 Powered pressure-reducing air mattress Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status

E0290 Hospital bed, fixed height, without side rails, with mattress Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of special bed; including mobility status


Updated 01/16/2015 87 / 140



E0291 Hospital bed, fixed height, without side rails, without mattress


E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress


E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress


E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress


E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress


E0296 Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress


E0297 Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress


E0300 Pediatric crib, hospital grade, fully enclosed Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of special bed; including mobility status

E0301 Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress


E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress


E0303 Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress



Updated 01/16/2015 88 / 140



E0304 Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress


E0316 Safety enclosure frame/canopy for use with hospital bed, any type


E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress


E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress


E0371 Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width


E0372 Powered air overlay for mattress, standard mattress length and width


E0373 Nonpowered advanced pressure reducing mattress Prior Authorization Required Medical Necessity History & Physical, including size, depth, location of decubiti

E0481 Intrapulmonary percussive ventilation system and related accessories

Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition.

E0483 High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each


E0484 Oscillatory positive expiratory pressure device, nonelectric, any type, each


E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Doc Req - Type of appliance, dx (e.g. TMJ, OSA). TMJ - narrative of therapeutic proc and hx of re-occurring TMJ. OSA - chart notes and a copy of diagnostic sleep studies

E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment

Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Doc Req - Type of appliance, dx (e.g. TMJ, OSA). TMJ - narrative of therapeutic proc and hx of re-occurring TMJ. OSA - chart notes and a copy of diagnostic sleep studies


Updated 01/16/2015 89 / 140



E0621 Sling or seat, patient lift, canvas or nylon Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status

E0625 Patient lift, bathroom or toilet, not otherwise classified Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status

E0627 Seat lift mechanism incorporated into a combination lift-chair mechanism


E0629 Separate seat lift mechanism for use with patient-owned furniture, nonelectric


E0630 Patient lift; hydraulic or mechanical, includes any seat, sling, strap(s), or pad(s)


E0637 Combination sit and stand system, any size, with seat lift feature, with or without wheels


E0638 Standing frame system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels


E0641 Standing frame system, multi-position (e.g., three-way stander,), any size including pediatric, with or without wheels

Prior Authorization Required Medical Necessity Letter of medical necessity, including condition being treated.

E0642 Standing frame system, mobile (dynamic stander), any size including pediatric

Prior Authorization Required Medical Necessity Letter of medical necessity, including condition being treated

E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure

Prior Authorization Required Medical Necessity Letter of medical necessity, including condition being treated.

E0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk



Updated 01/16/2015 90 / 140



E0657 Segmental pneumatic appliance for use with pneumatic compressor, chest


E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk

Pre-Service Review Recommended Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status

E0673 Segmental gradient pressure pneumatic appliance, half leg

Prior Authorization Required Medical Necessity Letter of medical necessity, including condition being treated

E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)

Prior Authorization Required Medical Necessity History and Physical including comorbidities, previously tried clinical interventions and operative report if any available

E0676 Intermittent limb compression device (includes all accessories), not otherwise specified


E0740 Incontinence treatment system, pelvic floor stimulator, monitor, sensor, and/or trainer

Pre-Service Review Recommended Investigative History and physical, plan of care, name of treatment system

E0744 Neuromuscular stimulator for scoliosis Pre-Service Review Recommended Medical Necessity History and Physical including comorbidities, previously tried clinical interventions and operative report if any available

E0745 Neuromuscular stimulator, electronic shock unit Prior Authorization Required Medical Necessity History and Physical including comorbidities, previously tried clinical interventions and operative report if any available

E0747 Osteogenesis stimulator, electrical, noninvasive, other than spinal applications

Pre-Service Review Recommended Medical Necessity History and Physical indicating location of fracture and any member comorbidites, If request is for non union of fracture, include date of fracture,serial radiographs detailing any history of healing,fracture gap,documentation of adequacy of immobilization

E0748 Osteogenic stimulator, electrical, non-invasive, spinal applications


E0749 Osteogenesis stimulator, electrical, surgically implanted Pre-Service Review Recommended Medical Necessity History and Physical indicating location of fracture and any member comorbidites, If request is for non union of fracture, include date of fracture,serial radiographs detailing any history of healing,fracture gap,documentation of adequacy of immobilization

E0755 Electronic salivary reflex stimulator (intraoral/noninvasive) Pre-Service Review Recommended Medical Necessity History and Physical including comorbidities, previously tried clinical interventions and operative report if any available


Updated 01/16/2015 91 / 140



E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive


E0761 Nonthermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device


E0762 Transcutaneous electrical joint stimulation device system, includes all accessories

Prior Authorization Required Investigative Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition

E0764 Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program

Prior Authorization Required Investigative History and physical, plan of care

E0765 FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting

Prior Authorization Required Medical Necessity History and Physical including comorbidities, previously tried clinical interventions and operative report if any available

E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type


E0769 Electrical stimulation or electromagnetic wound treatment device, not otherwise classified

Pre-Service Review Recommended Investigative Recent history and physical, plan of care, and documentation of medical necessity

E0770 Functional electrical stimulator, transcutaneous stimulation of nerve, and/or muscle groups, any type, complete system, not otherwise specified


E0912 Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, freestanding, complete with grab bar

Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity.

E0950 Wheelchair accessory, tray, each Prior Authorization Required Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition. Include invoice of cost for item.

E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each

Prior Authorization Required Specialized DME Letter of medical Necessity supporting need for the wheelchair accessory. Include invoice of cost for item.

E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control

Prior Authorization Required Medical Necessity Diagnosis, Abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength and Documented inability to propel a manual chair


Updated 01/16/2015 92 / 140



E0984 Power add-on to convert manual wheelchair to motorized wheelchair, tiller cotnrol

Prior Authorization Required Medical Necessity Diagnosis, Abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength and Documented inability to propel a manual chair

E0985 Wheelchair accessory, seat lift mechanism Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E0986 Manual wheelchair accessory, push activated power assist, each

Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair

Pre-Service Review Recommended Medical Necessity Documentation of medical necessity, including a physiatrist evaluation

E1002 Power seating system, tilt only Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E1003 Wheelchair accessory, power seating system, recline only, without shear reduction


E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear reduction


E1005 Wheelchair accessory, power seatng System, recline only, with power shear reduction


E1006 Power seating system, combination tilt and recline, without shear reduction


E1007 Power seating system, combination tilt and recline, with mechanical sheer reduction


E1008 Power seating system, combination tilt and recline, with power shear reduction


E1009 Addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each


E1010 Addition to power seating system, power leg elevation system, including leg rest, pair


E1011 Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)


E1014 Reclining back, addition to pediatric size wheelchair Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E1031 Rollabout chair, any and all types with casters five inches or greater

Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength


Updated 01/16/2015 93 / 140



E1035 Multi positional patient transfer system, with integrated seat, operated by caregiver


E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs


E1037 Transport chair, pediatric size Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

E1038 Transport chair, adult size, patient weight capacity up to an including 300 pounds


E1039 Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds


E1050 Fully-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests

Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.


Updated 01/16/2015 94 / 140



E1060 Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating legrests


E1070 Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away detachable footrest


E1083 Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests


E1084 Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating legrests


E1085 Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests



Updated 01/16/2015 95 / 140



E1086 Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests


E1087 High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests


E1088 High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating legrests


E1089 High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest


E1090 High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests



Updated 01/16/2015 96 / 140



E1092 Wide heavy-duty wheel chair, detachable arms (desk or full-length), swing-away detachable elevating legrests


E1093 Wide heavy-duty wheelchair, detachable arms, desk or full-length arms, swing-away detachable footrests


E1100 Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests


E1110 Semi-reclining wheelchair, detachable arms (desk or full-length) elevating legrest


E1130 Standard wheelchair; fixed full-length arms, fixed or swing-away, detachable footrests



Updated 01/16/2015 97 / 140



E1140 Wheelchair, detachable arms, desk or full-length; swing-away, detachable footrests


E1150 Wheelchair, detachable arms, desk or full-length swing-away detachable elevating legrests


E1160 Wheelchair, fixed full-length arms, swing-away, detachable, elevating legrests


E1161 Manual adult size wheelchair, includes tilt in space Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

E1170 Amputee wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests



Updated 01/16/2015 98 / 140



E1171 Amputee wheelchair, fixed full-length arms, without footrests or legrest


E1172 Amputee wheelchair, detachable arms (desk or full-length) without footrests or legrest


E1180 Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests


E1190 Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating legrests


E1195 Heavy duty wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests



Updated 01/16/2015 99 / 140



E1200 Amputee wheelchair; fixed full-length arms, swing-away, detachable footrests


E1220 Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification


E1221 Wheelchair with fixed arm, footrests Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.

E1222 Wheelchair with fixed arm, elevating legrests Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.

E1223 Wheelchair with detachable arms, footrests Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.


Updated 01/16/2015 100 / 140



E1224 Wheelchair with detachable arms, elevating legrests Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.

E1225 Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each


E1226 Wheelchair accessory, manual, fully reclining back (recline >80°), each


E1229 Wheelchair, pediatric size, not otherwise specified Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

E1230 Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength, Documented inability to propel a manual chair

E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system



Updated 01/16/2015 101 / 140



E1232 Wheelchair; Pediatric size, tilt-in-space, folding, adjustable, with seating system


E1233 Pediatric size, tilt-in-space, rigid, adjustable, without seating system


E1234 Pediatric size, tilt-in-space, folding adjustable with seating system


E1235 Pediatric size, folding, adjustable, with seating system Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.

E1236 Wheelchair, pediatric size, folding, adjustable, with seating system


E1237 Pediatric size, rigid, adjustable, without seating system Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.


Updated 01/16/2015 102 / 140



E1238 Pediatric size, folding, adjustable, without seating system Prior Authorization Required Specialized DME Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status, Surgical procedure description and Date if any performed.Include invoice of cost for item.

E1240 Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating legrest


E1250 Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest


E1260 Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest


E1270 Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests


E1280 Heavy duty wheelchair; detachable arms, desk or full-length, elevating legrests



Updated 01/16/2015 103 / 140



E1285 Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest


E1290 Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest


E1295 Heavy-duty wheelchair, fixed full-length arms, elevating legrest


E1399 Durable medical equipment, miscellaneous (Determine if an alternative


Unlisted Code Submit documentation to describe the services. Include a copy of the manufacturer cost invoice. From the ordering MD, request a letter of medical necessity for the item provided.

E1700 Jaw motion rehabilitation system Pre-Service Review Recommended Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status, Surgical procedure description and Date if any performed

E1701 Replacement cushions for jaw motion rehabilitation system, package of 6

Pre-Service Review Recommended Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status, Surgical procedure description and Date if any performed

E1702 Replacement measuring scales for jaw motion rehabilitation system, package of 200

Pre-Service Review Recommended Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status, Surgical procedure description and Date if any performed


Updated 01/16/2015 104 / 140



E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material

Prior Authorization Required Medical Necessity Letter of medical necessity containing the following information: Anticipated length of time patient will require the equipment, Description of medical condition requiring use of this equipment including mobility status, Surgical procedure description and Date if any performed

E1801 Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories


E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material


E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material


E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories


E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material


E1811 Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories


E1812 Dynamic knee, extension/flexion device with active resistance control



Updated 01/16/2015 105 / 140



E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material


E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories


E1818 Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories


E1820 Replacement soft interface material, dynamic adjustable extension/flexion device


E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device


E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material


E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material


E1831 Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories



Updated 01/16/2015 106 / 140



E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material


E1841 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories


E2120 Pulse generator system for tympanic treatment of inner ear endolymphatic fluid

Pre-Service Review Recommended Investigative History and physical, documentation for condition being treated

E2227 Manual wheelchair accessory, gear reduction drive wheel, each


E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each


E2230 Manual wheelchair accessory, manual standing system Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware


E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware


E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware


E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware


E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features


E2300 Power wheelchair accessory, power seat elevation system

Pre-Service Review Recommended Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E2310 Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware


E2311 Electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator


E2331 Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware


E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27 in



Updated 01/16/2015 107 / 140



E2342 Non-standard seat frame depth, 20 or 21 inches Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E2343 Power wheelchair accessory, nonstandard seat frame depth, 22-25 in


E2351 Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface


E2500 Speech generating device, digitized speech, using pre-recorded messages, less than or equal to eight minutes recording time


E2502 Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time


E2504 Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time


E2506 Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time


E2508 Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device


E2510 Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access


E2511 Speech generating software program, for personal computer or personal digital assistant


E2512 Accessory for speech generating device, mounting system


E2599 Accessory for speech generating device, not otherwise classified


E2603 Skin protection wheelchair seat cushion, width less than 22 in., any depth

Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory. Include invoice of cost for item.

E2604 Width 22 in. or greater, any depth Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory. Include invoice of cost for item.

E2605 Positioning wheelchair seat cushion, width less than 22 in., any depth




Updated 01/16/2015 108 / 140



E2607 Skin protection and positioning wheelchair seat cushion, width less than 22 in., any depth



E2609 Custom fabricated wheelchair seat cushion, any size Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory. Include invoice of cost for item.

E2610 Wheelchair seat cushion, powered Prior Authorization Required Medical Necessity Letter of medical Necessity supporting need for the wheelchair accessory

E2613 Positioning wheelchair back cushion, posterior, width less than 22 in., any height, including any type mounting hardware


E2614 Width 22 in. or greater, any height, including any type mounting hardware


E2615 Posterior-lateral, width less than 22 in., any height, including any type mounting hardware




E2617 Custom fabricated wheelchair back cushion, any size, includes any type mounting hardware


E2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware




E2622 Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth


E2623 Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth


E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth


E2625 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth


E8000 Gait trainer, pediatric size, posterior support, includes all accessories and components

Pre-Service Review Recommended Medical Necessity Letter of medical necessity including PT/OT evaluation

E8001 Gait trainer, pediatric size, upright support, includes all accessories and components

Pre-Service Review Recommended Medical Necessity Letter of medical necessity including PT/OT evaluation

E8002 Gait trainer, pediatric size, anterior support, includes all accessories and components

Pre-Service Review Recommended Medical Necessity History and Physical including disease condition requiring PT management, plan of care

G0151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes

Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care


Updated 01/16/2015 109 / 140



G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes


G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes


G0154 Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes


G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

Pre-Service Review Recommended Medical Necessity History and Physical, including functional capacity, location, if metastatic, and number of lesions

G0219 PET imaging whole body; melanoma for noncovered indications


G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment


G0252 PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)


G0255 Current perception threshold/sensory nerve conduction test, (SNCT) per limb, any nerve

Pre-Service Review Recommended Investigative Submit History and Physical, medical necessity documentation, procedure report

G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval


G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206)


G0281 Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as

Pre-Service Review Recommended Investigative Pre Operative Evaluation, History and Physical, and Operative report, including size and source of wound

G0282 Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281


G0295 Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses


G0329 Electromagnetic therapy, to one or more areas for chronic stage III or IV pressure ulcers, arterial ulcers, diabetic ulcers and venous ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care

Pre-Service Review Recommended Investigative Pre Operative Evaluation, History and Physical, and Operative report, including size and source of wound,


Updated 01/16/2015 110 / 140



G0339 Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment


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 5 sessions per course of treatment


G0341 Percutaneous islet cell transplant, includes portal vein catheterization and infusion


G0342 Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion


G0343 Laparotomy for islet cell transplant, includes portal vein catheterization and infusion


G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels

Pre-Service Review Recommended Medical Necessity History and Physical, treatment plan.

G0428 Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)

Pre-Service Review Recommended Investigative Pre Operative Evaluation, History and Physical with description of defect including whether it is full thickness, size, if there has been prior arthroscopic/surgical repair, and Operative report

G0448 Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing

Prior Authorization Required Medical Necessity History and Physical, documentation of medical necessity and procedure report

G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment

Pre-Service Review Recommended Investigative History and Physical, documentation of medical necessity

G0464 Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3

Pre-Service Review Recommended Investigative Submit History and Physical, medical necessity documentation, procedure report

G6021 Unlisted procedure, intestine Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required


G9143 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)

Pre-Service Review Recommended Investigative History and physical, documentation of medical necessity


Updated 01/16/2015 111 / 140



H0031 Mental health assessment, by nonphysician Pre-Service Review Recommended Medical Necessity Submit chart notes for actual services billed, diagnosis verification and provider state licensure or BCBA certification

H0032 Mental health service plan development by nonphysician Pre-Service Review Recommended Medical Necessity Submit chart notes for actual services billed, diagnosis verification and provider state licensure or BCBA certification

H2000 Comprehensive multidisciplinary evaluation Pre-Service Review Recommended Medical Necessity Clincial notes for this procedure and DOS from each discipline and licensure of each discipline

H2001 Rehabilitation program, per 1/2 day Pre-Service Review Recommended Medical Necessity Initial assessment, discharge summary, progress notes. Licensure of facility

H2014 Skills training and development, per 15 minutes Pre-Service Review Recommended Medical Necessity Submit chart notes for actual services billed, diagnosis verification and provider state licensure or BCBA certification

H2019 Therapeutic behavioral services per 15 minutes Pre-Service Review Recommended Medical Necessity Submit chart notes for actual services billed, diagnosis verification and provider state licensure or BCBA certification

H2020 Therapeutic behavioral services per diem Pre-Service Review Recommended Medical Necessity Initial assessment, progress notes for the services provided

J0129 Injection, abatacept, 10 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

J0135 Injection, adalimumab (Humira) 20 mg Pre-Service Review Recommended Medical Necessity Fax BA to Pharmacy review @ 888-260-9836. Submit office notes related to condition, medical necessity and documentation of previous therapies/treatments tried,dosage and duration of treatment

J0215 Injection, alefacept, 0.5 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

J0490 Injection, belimumab, 10 mg Prior Authorization Required Medical Necessity History and physical, documentation of medical necessity, treatment plan

J0717 Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)

Prior Authorization Required Medical Necessity History and Physical, clinical notes related to a condition being treated, documentation of previous therapies tried and failed.

J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg Pre-Service Review Recommended Medical Necessity Submit History and physical, documentation of medical necessity.

J0800 Injection, corticotropin, up to 40 units Pre-Service Review Recommended Medical Necessity History and Physical including response to prior treatment


Updated 01/16/2015 112 / 140



J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) Prior Authorization Required Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) Prior Authorization Required Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

J0885 Injection, epoetin alfa, (for non-ESRD use), 1000 units Prior Authorization Required Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

J0886 Injection, epoetin alfa, 1000 units (for ESRD on dialysis) Prior Authorization Required Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

J0887 Injection, epoetin beta, 1 microgram, (for ESRD on dialysis)

Prior Authorization Required Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

J0888 Injection, epoetin beta, 1 microgram, (for non-ESRD use) Prior Authorization Required Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

J0890 Injection, Peginesatide, 0.1 mg (for ESRD on dialysis), Omontys

Pre-Service Review Recommended Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

J1325 Injection, epoprostenol, 0.5 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

J1438 Injection Etanercept (Enbrel) 25 MG Pre-Service Review Recommended Medical Necessity Fax BA to Pharmacy review @ 888-260-9836. Submit office notes related to condition, medical necessity and documentation of previous therapies/treatments tried,dosage and duration of treatment

J1442 Injection, filgrastim (G-CSF), 1 microgram Pre-Service Review Recommended Medical Necessity Effective DOS 8/30/2014 submit History and Physical, documentation of medical necessity including prior treatments

J1446 Injection, TBO-filgrastim, 5 micrograms Pre-Service Review Recommended Medical Necessity Effective DOS 8/30/2014 submit History and Physical, documentation of medical necessity including prior treatments

J1459 Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg

Prior Authorization Required Medical Necessity History and Physical and recent lab work

J1556 Injection, immune globulin (bivigam), 500 mg Pre-Service Review Recommended Medical Necessity History and Physical and recent lab work


Updated 01/16/2015 113 / 140



J1557 Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg


J1559 Injection, immune globulin (Hizentra), 100 mg Prior Authorization Required Medical Necessity History and Physical and recent lab workJ1561 Injection, immune globulin, (Gamunex), intravenous,

nonlyophilized (e.g., liquid), 500 mg Prior Authorization Required Medical Necessity History and Physical and recent lab work

J1562 Injection, immune globulin (Vivaglobin), 100 mg Prior Authorization Required Medical Necessity History and Physical and recent lab workJ1566 Injection, immune globulin, intravenous, lyophilized (e.g.,

powder), not otherwise specified, 500 mg Prior Authorization Required Medical Necessity History and Physical and recent lab work

J1568 Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg


J1569 Injection, immune globulin, (Gammagard liquid), intravenous, nonlyophilized, (e.g., liquid), 500 mg


J1572 Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg


J1599 Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg


J1602 Injection, golimumab, 1 mg, for intravenous use Prior Authorization Required Medical Necessity History and Physical, clinical notes related to a condition being treated, documentation of previous therapies tried and failed.

J1745 Injection infliximab, 10 mg Prior Authorization Required Medical Necessity History and physical including prior treatments and results. Do not send infusion records!

J2170 Injection, mecasermin, 1 mg Prior Authorization Required Medical Necessity History and Physical, including prior treatments and proposed treatment plan

J2357 Injection, omalizumab, 5 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

J2505 Injection, pegfilgrastim, 6 mg Pre-Service Review Recommended Medical Necessity Effective DOS 8/30/2014 submit History and Physical, documentation of medical necessity including prior treatments

J2796 Injection, romiplostim, 10 mcg Pre-Service Review Recommended Medical Necessity History and Physical, Office notes related to a condition being treated

J2940 Injection, somatrem, 1 mg Pre-Service Review Recommended Medical Necessity If has had previous treatment, use the following criteria:For Children: History and physical, office notes related to condition being treated; notes demonstrating height velocity over previous year, and bone age or epiphyses confirmed open. For Adults: History and physical, office notes related to condition being treated; notes demonstrating clinical benefit (e.g., improvement in bone density, or cholesterol studies)


Updated 01/16/2015 114 / 140



J2941 Injection, somatropin, 1 mg Pre-Service Review Recommended Medical Necessity If had previous treatment, indicate which preferred product was used; and use following criteria.For Children: History and physical, office notes related to condition being treated; notes demonstrating height velocity over previous year, and bone age or epiphyses confirmed open. For Adults: History and physical, office notes related to condition being treated; notes demonstrating clinical benefit (e.g., improvement in bone density, or cholesterol studies)

J3262 Injection, tocilizumab, 1 mg (Actemra) Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, dosage and duration of treatment, office notes related to condition

J3285 Injection, treprostinil, 1 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

J3357 Injection, ustekinumab, 1 mg Prior Authorization Required Medical Necessity History and Physical, clinical notes from ordering provider, treatment plan

J3490 Unclassified drugs Pre-Service Review Recommended where description of service is available, otherwise Retrospective Medical Review Required

Unlisted Code Submit documentation to describe the medication and procedure report. Include chart notes with drug name, NDC number and quantity.

J3520 Edetate disodium, per 150 mg Pre-Service Review Recommended Medical Necessity Clinical notes for date of service and plan of careJ3590 Unclassified biologics Pre-Service Review Recommended Medical Necessity History and physical demonstrating reason for

requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/ treatments tried.

J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose

Pre-Service Review Recommended Medical Necessity Submit procedure notes indicating which joint is being treated.

J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose


J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose


J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg


J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose


J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose



Updated 01/16/2015 115 / 140



J7500 Azathioprine, oral, 50 mg Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

J7501 Azathioprine, parenteral, 100 mg Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

J7502 Cyclosporine, oral, 100 mg Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

J7504 Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg


J7505 Muromonab-CD3, parenteral, 5 mg Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

J7525 Tacrolimus, parenteral, 5 mg Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

J7599 Immunosuppressive drug, not otherwise classified Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

J8499 Prescription drug, oral, non-chemotherapeutic, NOS (Includes: Revlimid)


Unlisted Code Submit documentation to describe the services; specify the drug name and NDC number, include chart notes.

J8565 Gefitinib, oral, 250 mg (Iressa) Pre-Service Review Recommended Medical Necessity Fax BA to Pharmacy review @ 888-260-9836. Submit office notes related to condition, medical necessity and documentation of previous therapies/treatments tried,dosage and duration of treatment

J8999 Prescription drug, oral, chemotherapeutic, NOS (includes: Sprycel andTasigna, Erlotinib, Nexavar and Sutent)

Pre-Service Review Recommended Medical Necessity Name of drug; History and physical including primary condition being treated; response to prior treatments

J9035 Injection, bevacizumab, 10 mg Prior Authorization Required Medical Necessity History and Physical including prior treatments and proposed treatment plan. Please do not send infusion records.

J9055 Injection, cetuximab, 10 mg Prior Authorization Required Medical Necessity History and Physical, including prior treatments and proposed treatment plan


Updated 01/16/2015 116 / 140



J9300 Injection, gemtuzumab ozogamicin, 5 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

J9302 Injection, ofatumumab, 10 mg (Arzerra) Pre-Service Review Recommended Medical Necessity History and physical demonstrating reason for requested medication, dosage and duration of treatment, office notes related to condition

J9303 Injection, panitumumab, 10 mg Prior Authorization Required Medical Necessity History and Physical, including prior treatments and proposed treatment plan

J9306 Injection, pertuzumab, 1 mg Pre-Service Review Recommended Medical Necessity History and Physical, including prior treatments and proposed treatment plan

J9310 Injection, rituximab, 100 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, dosage and duration of treatment, office notes related to condition. Do not send infusion records!

J9315 Injection, romidepsin, 1 mg (Istodax) Pre-Service Review Recommended Medical Necessity History and Physical, documentation of medical necessity, treatment plan

J9330 Injection, temsirolimus, 1 mg (Torisel) Pre-Service Review Recommended Medical Necessity Submit office notes related to condition, medical necessity and documentation of previous therapies/treatments tried,dosage and duration of treatment

J9354 Injection, ado-trastuzumab emtansine, 1 mg Pre-Service Review Recommended Medical Necessity History and Physical, including prior treatments and proposed treatment plan

J9355 Injection, trastuzumab, 10 mg Prior Authorization Required Medical Necessity History and physical demonstrating reason for requested medication, and lab work demonstrating HER-2/neu over expression. Do not send infusion records!

J9400 Injection, ziv-aflibercept, 1 mg Pre-Service Review Recommended Medical Necessity History and Physical, documentation of medical necessity, treatment plan

J9999 Not otherwise classified, antineoplastic drugs Pre-Service Review Recommended Medical Necessity History and Physical, clinical notes related to a condition being treated, medical necessity documentation including drug name, NDC number and quantity

K0003 Lightweight wheelchair Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength. Include invoice of cost for item.


Updated 01/16/2015 117 / 140



K0004 High strength, lightweight wheelchair Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

K0005 Ultralight weight wheelchair Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

K0008 Custom manual wheelchair base Prior Authorization Required Specialized DME History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition). Past experience if any using similar equipment,

K0009 Other manual wheelchair/base Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

K0010 Standard – weight frame motorized/power wheelchair Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength, Documented inability to propel a manual chair

K0011 Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking

Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength, Documented inability to propel a manual chair


Updated 01/16/2015 118 / 140



K0012 Lightweight portable motorized/power wheelchair Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength, Documented inability to propel a manual chair

K0013 Custom motorized/power wheelchair base Prior Authorization Required Specialized DME History and Physical, Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition). Past experience if any using similar equipment.

K0014 Other motorized/power wheelchair base Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength, Documented inability to propel a manual chair

K0108 Wheelchair component or accessory, not otherwise specified


K0455 Infusion pump used for uninterrupted parenteral administration of medication, (e.g., epoprostenol or treprostinol)

Pre-Service Review Recommended Medical Necessity History and Physical indicating why treatment is being done

K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type


K0607 Replacement battery for automated external defibrillator, each


K0608 Replacement garment for use with automated external defibrillator, each


K0609 Replacement electrodes for use with automated external defibrillator, each


K0669 Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from SADMERC



Updated 01/16/2015 119 / 140



K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds


K0801 Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds


K0802 Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds


K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds


K0807 Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds


K0808 Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds



Updated 01/16/2015 120 / 140



K0812 Power operated vehicle, not otherwise classified Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds


K0814 Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds


K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds


K0816 Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds


K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds



Updated 01/16/2015 121 / 140



K0821 Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds


K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds




K0824 Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds


K0825 Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds


K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds



Updated 01/16/2015 122 / 140



K0827 Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds


K0828 Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more


K0829 Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601 pounds or more


K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds


K0831 Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds


K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds



Updated 01/16/2015 123 / 140



K0836 Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds


K0837 Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds


K0838 Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds


K0839 Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds


K0840 Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more


K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds



Updated 01/16/2015 124 / 140



K0842 Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds


K0843 Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds



Pre-Service Review Recommended Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength





K0851 Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds



Updated 01/16/2015 125 / 140



K0852 Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds


K0853 Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds


K0854 Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more


K0855 Power wheelchair, group 3 extra heavy duty, captain's chair, patient weight capacity 601 pounds or more







Updated 01/16/2015 126 / 140



K0858 Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds


K0859 Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds


K0860 Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds






K0863 Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds



Updated 01/16/2015 127 / 140



K0864 Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more








K0871 Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds





Updated 01/16/2015 128 / 140




Pre-Service Review Recommended Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

K0879 Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds


K0880 Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds




K0885 Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds





Updated 01/16/2015 129 / 140



K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds


K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds


K0898 Power wheelchair, not otherwise classified Prior Authorization Required Medical Necessity History and Physical to Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition, Past experience if any using similar equipment, Evaluation of upper extremity strength

K0899 Power mobility device, not coded by DME PDAC or does not meet criteria


K0900 Customized durable medical equipment, other than wheelchair

Prior Authorization Required Specialized DME History and Physical, Include the following: diagnosis; abilities and limitations as they relate to the equipment (e.g., degree of independence/ dependence, frequency and nature of the activities the patient performs, duration of medical condition). Past experience if any using similar equipment.

L1499 Spinal orthotic, NOS Pre-Service Review Recommended Medical Necessity Need description of equipment provided, letter of medical necessity including current medical condition and mobility status

L1846 Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated


L3999 Upper limb orthosis, not otherwise specified Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition.


Updated 01/16/2015 130 / 140



L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type


L5857 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type


L5858 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type

Prior Authorization Required Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition.

L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source


L5999 Lower extremity prosthesis, not otherwise specified Pre-Service Review Recommended Medical Necessity Specific description of item, physical therapist evaluation and documentation of functional capacity.

L6025 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, 2 batteries, charger, myoelectric control of terminal device

Prior Authorization Required Medical Necessity History and physical, letter of medical necessity and functional status eval from physiatrist or physical therapist.

L6026 Transcarpal/metacarpal 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)


L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement

Prior Authorization Required Medical Necessity History and Physical, physiatrist documentation of physical capacity

L6880 Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)

Prior Authorization Required Medical Necessity History and Physical, physiatrist documentation of physical capacity

L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 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, 2 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, 2 batteries and one charger, myoelectronic control of terminal device



Updated 01/16/2015 131 / 140



L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device


L6965 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

Pre-Service Review Recommended Medical Necessity History and physical, letter of medical necessity and functional status eval from physiatrist or physical therapist.

L6975 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal dev


L7007 Electric hand, switch or myoelectric controlled, adult Prior Authorization Required Medical Necessity History and physical, letter of medical necessity and functional status eval from physiatrist or physical therapist.

L7008 Electric hand, switch or myoelectric, controlled, pediatric Prior Authorization Required Medical Necessity History and physical, letter of medical necessity and functional status eval from physiatrist or physical therapist.

L7009 Electric hook, switch or myoelectric controlled, adult Prior Authorization Required Medical Necessity History and physical, letter of medical necessity and functional status eval from physiatrist or physical therapist.

L7045 Electric hook, switch or myoelectric controlled, pediatric Prior Authorization Required Medical Necessity History and physical, letter of medical necessity and functional status eval from physiatrist or physical therapist.

L7181 Electronic elbow, microprocessor simultaneous control of elbow and terminal device

Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity from Physiatrist or Occupational Therapist, including functional status and assesment of rehab potential

L7190 Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled


L7191 Electronic elbow, child, Variety Village or equal, myoelectronically controlled


L7259 Electronic wrist rotator, any type Pre-Service Review Recommended Medical Necessity Submit History and Physical, documentation of medical necessity

L8499 Unlisted procedure for miscellaneous prosthetic services Pre-Service Review Recommended Medical Necessity Need description of equipment provided, letter of medical necessity including current medical condition and mobility status

L8600 Implantable breast prosthesis, silicone or equal Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report.

L8609 Artificial cornea Pre-Service Review Recommended Medical Necessity History and physical, prosthesis typeL8614 Cochlear device, includes all internal and external

components Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, Operative Report, Previous

use of hearing aids, Level of hearing Impairment


Updated 01/16/2015 132 / 140



L8619 Cochlear implant external speech processor, replacement Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level of hearing Impairment

L8679 Implantable neurostimulator, pulse generator, any type Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity including length of time equipment needed, functional status if applicable and description of medical condition

L8680 Implantable neurostimulator electrode, each Prior Authorization Required Medical Necessity Recent History and Physical, plan of care, and documentation of medical necessity

L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator


L8682 Implantable neurostimulator radiofrequency receiver Prior Authorization Required Medical Necessity Letter of Medical Necessity including length of time equipment needed,functional status if applicable and description of medical condition

L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver


L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement


L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension


L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension


L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension


L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension


L8689 External recharging system for battery (internal) for use with implantable neurostimulator


L8690 Auditory osseointegrated device, includes all internal and external components

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level of hearing Impairment

L8691 Auditory osseointegrated device, external sound processor, replacement


L8692 Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment

Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, Operative Report, Previous use of hearing aids, Level of hearing Impairment

L8693 Auditory osseointegrated device abutment, any length, replacement only



Updated 01/16/2015 133 / 140



L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only

Prior Authorization Required Medical Necessity Peer Reviewed Literature supporting requested procedure, Recent History and Physical

L8699 * For Retrospective Review Only* Prosthetic implant, not otherwise specified

Pre-Service Review Recommended Medical Necessity Submit the description of an item provided, cost invoice and a letter of medical necessity from the ordering physician. No invoice needed if pricing is not required.

L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

Pre-Service Review Recommended Medical Necessity Need description of equipment provided, letter of medical necessity including current medical condition and mobility status

M0076 Prolotherapy Pre-Service Review Recommended Investigative History and physical, plan of careM0300 IV chelation therapy (chemical endarterectomy) Pre-Service Review Recommended Medical Necessity History and Physical including toxic exposuresP9020 Platelet rich plasma, each unit Prior Authorization Required Investigative History and Physical, plan of care description of

wound location, depth, sizeQ0480 Driver for use with pneumatic ventricular assist device,

replacement onlyPre-Service Review Recommended Medical Necessity If ventricular assist device allowed previously, do not

need to request records. History and PhysicalQ0481 Microprocessor control unit for use with electric

ventricular assist device, replacement onlyPre-Service Review Recommended Medical Necessity If ventricular assist device allowed previously, do not

need to request records. History and PhysicalQ0482 Microprocessor control unit for use with

electric/pneumatic combination ventricular assist device, replacement only

Pre-Service Review Recommended Medical Necessity If ventricular assist device allowed previously, do not need to request records. History and Physical

Q0483 Monitor/display module for use with electric ventricular assist device, replacement only


Q0484 Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0485 Monitor control cable for use with electric ventricular assist device, replacement only


Q0486 Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only


Q0487 Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only


Q0488 Power pack base for use with electric ventricular assist device, replacement only


Q0489 Power pack base for use with electric/pneumatic ventricular assist device, replacement only


Q0490 Emergency power source for use with electric ventricular assist device, replacement only


Q0491 Emergency power source for use with electric/pneumatic ventricular assist device, replacement only


Q0492 Emergency power supply cable for use with electric ventricular assist device, replacement only


Q0493 Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only



Updated 01/16/2015 134 / 140



Q0494 Emergency hand pump for use with electric/pneumatic ventricular assist device, replacement only


Q0495 Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0496 Battery for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0497 Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0498 Holster for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0499 Belt/vest for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0500 Filters for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0501 Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only


Q0502 Mobility cart for pneumatic ventricular assist device, replacement only


Q0503 Battery for pneumatic ventricular assist device, replacement only, each


Q0504 Power adapter for pneumatic ventricular assist device, replacement only, vehicle type


Q0505 Miscellaneous supply or accessory for use with ventricular assist device


Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device


Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device


Q0509 Miscellaneous supply or accessory for use any implanted ventricular assist device for which payment was not made under Medicare Part A


Q2026 Injection, Radiesse, 0.1ML Pre-Service Review Recommended Cosmetic - Potential Contract Exclusion

Clinical notes from doctor's office related to this condition and treatment

Q2028 Injection, sculptra, 0.5 mg Pre-Service Review Recommended Cosmetic - Potential Contract Exclusion

Clinical notes from the doctor's office related to this condition and treatment

Q2043 Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion

Prior Authorization Required Medical Necessity History and physical, clinical notes related to a condition being treated, treatment plan

Q4074 Iloprost, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, up to 20 mcg

Pre-Service Review Recommended Medical Necessity History and Physical, Office notes related to a condition being treated


Updated 01/16/2015 135 / 140



Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) Pre-Service Review Recommended Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

Q4097 Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg

Pre-Service Review Recommended Medical Necessity History and Physical and recent lab work

Q9972 Injection, epoetin beta, 1 microgram, (for ESRD on dialysis)

Pre-Service Review Recommended Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

Q9973 Injection, epoetin beta, 1 microgram, (non-ESRD use) Pre-Service Review Recommended Medical Necessity Submit chart notes from the ordering physician including history and physical with Hgb level and transferrin saturation or ferritin level within 1 month of initiating ESA and monthly.

S0088 Imatinib, 100 mg Prior Authorization Required Medical Necessity If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S0155 Sterile dilutant for epoprostenol, 50 ml Pre-Service Review Recommended Medical Necessity History and Physical including treatment regimen and prior failed therapies

S0157 Becaplermin gel 0.01%, 0.5 gm Pre-Service Review Recommended Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

S0198 Injection, pegaptanib sodium, 0.3 mg Pre-Service Review Recommended Medical Necessity History and physical demonstrating reason for requested medication, lab work if applicable, dosage and duration of treatment, office notes related to condition, medical necessity and documentation of previous therapies/treatments tried

S0812 Phototherapeutic keratectomy (PTK) Pre-Service Review Recommended Medical Necessity Pre Operative Evaluation, History and Physical, and Operative report

S1002 Customized item (list in addition to code for basic item) Pre-Service Review Recommended Medical Necessity Need description of equipment provided, letter of medical necessity including current medical condition and mobility status

S1030 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)

Pre-Service Review Recommended Medical Necessity History and Physical including currect medications, compliance with diet, testing and exercise program; frequency and severity of hypoglycemic episodes; hypoclycemic awareness; occupation and support system

S1031 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)


S1090 Mometasone furoate sinus implant, 370 micrograms Pre-Service Review Recommended Investigative HIstory and Physical, documentation of medical necessity, operative report


Updated 01/16/2015 136 / 140



S2053 Transplantation of small intestine and liver allografts Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S2054 Transplantation of multivisceral organs Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S2055 Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor

Pre-Service Review Recommended Transplant Name of recipient, organ transplant evaluation.

S2060 Lobar lung transplantation Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S2061 Donor lobectomy (lung) for transplantation, living donor Pre-Service Review Recommended Transplant Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S2065 Simultaneous pancreas kidney transplantation Pre-Service Review Recommended Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S2080 Laser-assisted uvulopalatoplasty (LAUP) Prior Authorization Required Investigative History and Physical, including Sleep study results, results of CPAP trial

S2095 Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres

Pre-Service Review Recommended Medical Necessity History and Physical, including prior treatment regimens.

S2102 Islet cell tissue transplant from pancreas; allogeneic Prior Authorization Required Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S2103 Adrenal tissue transplant to brain Prior Authorization Required Investigative Recent History and Physical, plan of care, and documentation of medical necessity

S2107 Adoptive immunotherapy i.e. development of specific antitumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment

Pre-Service Review Recommended Investigative History and Physical, treatment plan

S2117 Arthroereisis, subtalar Pre-Service Review Recommended Investigative History and physical, operative reportS2120 Low density lipoprotein (LDL) apheresis using heparin-

induced extracorporeal LDL precipitationPre-Service Review Recommended Medical Necessity History and Physical including prior treatments and

LDL lab test resultsS2140 Cord blood harvesting for transplantation, allogeneic Prior Authorization Required Transplant If transplant approval on record: Date of Transplant

If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant

S2142 Cord blood-derived stem-cell transplantation, allogeneic Prior Authorization Required Transplant If transplant approval on record: Date of Transplant If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant


Updated 01/16/2015 137 / 140



S2150 Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications including pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization


S2152 Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor (s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up


S2230 Implantation of magnetic component of semi-implantavle hearing device on ossicles in middle ear


S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar


S2360 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; cervical


S2361 Each additional cervical vertebral body (list separately in addition to code for primary procedure)


S3721 Prostate cancer antigen 3 (PCA3) testing Pre-Service Review Recommended Investigative HIstory and Physical, documentation of medical necessity

S3722 Dose optimization by area under the curve (AUC) analysis, for infusional 5-fluorouracil

Pre-Service Review Recommended Investigative History and Physical, specific test name

S3852 DNA analysis for APOE essilon 4 allele for susceptibility to Alzheimer's disease


S3854 Gene expression profiling panel for use in the management of breast cancer treatment


S3855 Genetic testing for detection of mutations in the presenilin - 1 gene

Pre-Service Review Recommended Investigative History and Physical, office notes for visit at which test ordered

S3861 Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome


S3865 Comprehensive gene sequence analysis for hypertrophic cardiomyopathy

Pre-Service Review Recommended Medical Necessity History and Physical, medical necessity documentation

S3866 Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family

Pre-Service Review Recommended Medical Necessity History and Physical, medical necessity documentation

S3870 Comparative genomic hybrization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or mental retardation

Pre-Service Review Recommended Medical Necessity History and physical, documentation of medical necessity

S3890 DNA analysis, fecal, for colorectal cancer screening Pre-Service Review Recommended Investigative Submit History and Physical, medical necessity documentation

S3900 Surface electromyography (EMG) Pre-Service Review Recommended Medical Necessity History and Physical, office notes, date of service. S3905 Noninvasive electrodiagnostic testing with automatic

computerized hand-held device to stimulate and measure neuromuscular signals in diagnosing and evaluating systemic and entrapment neuropathies



Updated 01/16/2015 138 / 140



S8032 Low-dose computed tomography for lung cancer screening


S8035 Magnetic source imaging Pre-Service Review Recommended Medical Necessity History and Physical, including condition being treated

S8130 Interferential current stimulator, 2 channel Prior Authorization Required Investigative History and Physical, plan of careS8131 Interferential current stimulator, 4 channel Prior Authorization Required Investigative History and Physical, plan of careS8262 Mandibular orthopedic repositioning device, each Pre-Service Review Recommended Medical Necessity Fax BA to Dental Review @ 425-918-5956. Request

diagnosis, prognosis and chart notes including history of non-invasive or non-surgical attempts to treat the TMJ

S8930 Electrical stimulation of auricular acupuncture points; each 15' of personal one-on-one contact with the patient

Pre-Service Review Recommended Investigative Hstory and physical, documentation of medical necessity, treatment plan

S9055 Procuren or other growth factor preparation to promote wound healing

Prior Authorization Required Medical Necessity History and Physical, including previous conservative treatments and surgeries tried

S9090 Vertebral axial decompression, per session Pre-Service Review Recommended Investigative Submit History and Physical, plan of careS9097 Home visit for wound care Pre-Service Review Recommended Medical Necessity Chart notes for each home visit, including description

of wound, size, depth, and character of drainage

S9122 Home health aide or certified nurse assistant, providing care in the home; per hour


S9123 Nursing care, in the home; by registered nurse, per hour Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care

S9124 Nursing care, in the home; by licensed practical nurse, per hour


S9125 Respite care, in the home, per diem Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

S9127 Social work visit, in the home, per diem Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

S9128 Speech therapy, in the home, per diem Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

S9129 Occupational therapy, in the home, per diem Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

S9131 Physical therapy; in the home, per diem Pre-Service Review Recommended Medical Necessity Notes documenting medical necessity, each date of service, and homebound status. Include plan of care

S9145 Insulin pump initiation, instruction in initial use of pump (pump not included)

Pre-Service Review Recommended Medical Necessity Physician signed orders, Pre treatment plan evaluation including history physical, etc., Treatment plan

S9209 Home management of preterm premature rupture of membranes (PPROM), including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment, per diem



Updated 01/16/2015 139 / 140



S9211 Home management of gestational hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, per diem


S9212 Home management of postpartum hypertension, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem


S9213 Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem


S9214 Home management of gestational diabetes, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; per diem


S9347 Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); per diem


S9355 Home infusion therapy, chelation therapy (drugs and nursing visits coded separately), per diem


S9381 Delivery or service to high risk areas requiring escort or extra protection, per visit


S9433 Medical food nutritionally complete, administered orally, providing 100% of nutritional intake

Pre-Service Review Recommended Medical Necessity History and Physical, documentation of medical necessity

S9445 Patient education, not otherwise classified, nonphysician provider, individual, per session

Pre-Service Review Recommended Medical Necessity Clinical notes documenting disease being treated and expected plan of treatment

S9446 Patient education, not otherwise classified, nonphysician provider, group, per session

Pre-Service Review Recommended Medical Necessity Clinical notes documenting disease being treated and expected plan of treatment

S9484 Crisis intervention mental health services, per hour Pre-Service Review Recommended Psychiatric Clinical record for this procedure and DOSS9542 Home injectable therapy, not otherwise classified, (drugs

and nursing visits coded separately), per diemPre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for

each discipline providing treatmentS9558 Home injectable therapy; growth hormone, including

administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded 99.24 Injection of hormone


S9590 Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); (drugs and nursing visits coded separately), per diem


S9960 Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)

Prior Authorization Required Medical Necessity Submit progress notes for last 24 hours prior to transport, physician order including medical records supporting rationale for transport

S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)

Prior Authorization Required Medical Necessity Submit progress notes for last 24 hours prior to transport, physician order including medical records supporting rationale for transport


Updated 01/16/2015 140 / 140



T1000 Private duty/independent nursing service(s), licensed, up to 15 minutes


T1002 RN services, up to 15 minutes Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

T1003 LPN/LVN services, up to 15 minutes Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

T1004 Services of a qualified nursing aide, up to 15 minutes Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

T1005 Respite care services, up to 15 minutes Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

T1021 Home health aide or certified nurse assistant, per visit Pre-Service Review Recommended Medical Necessity Chart notes for each home visit and therapy notes for each discipline providing treatment

T1022 Contracted home health agency services, all services provided under contract, per day


T1024 Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter


T1025 Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem


T1026 Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, medical and psychosocial impairments, per hour


T2007 Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2) hour increments

Pre-Service Review Recommended Medical Necessity Transport notes documenting necessity of service

T2048 Behavioral health; long-term care residential (non-acute care in a residential treatment program where stay is typically longer than 30 days), with room and board, per diem.

Pre-Service Review Recommended Psychiatric Initial psychiatric assessment, discharge summary, MD orders and MD progress notes Licensure of facility

T5999 Supply, not otherwise specified Pre-Service Review Recommended Medical Necessity Need description of equipment provided, letter of medical necessity including current medical condition and mobility status

V5095 Semi-implantable middle ear hearing prosthesis Prior Authorization Required Investigative History and Physical, Operative reportV5336 Repair/modification of augmentative communicative

system or device (excludes adaptive hearing aid) Pre-Service Review Recommended Medical Necessity Letter of Medical Necessity including documenting

need for repair of modification

prior authorization code list 2015 - premera blue cross• custom fabricated knee braces • dynamic...

Documents