2021 Commercial Outpatient Benefit Preauthorization Fully ... · CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including

Procedure Code Service/Category Description Medical Policy Number Medical Policy Title Updates

71271 RadiologyComputed tomography, thorax, low dose for lung cancer screening,

without contrast material(s)AIM Guidelines Add effective 01/01/2021

81168 Molecular and Genetic LabCCND1/IGH (t(11;14)) (eg, mantle cell lymphoma) translocation

analysis, major breakpoint, qualitative and quantitative, if performedAIM Guidelines Add effective 01/01/2021

81191 Molecular and Genetic LabNTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors)

translocation analysisAIM Guidelines Add effective 01/01/2021





81194 Molecular and Genetic LabNTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3)

(eg, solid tumors) translocation analysisAIM Guidelines Add effective 01/01/2021

81278 Molecular and Genetic Lab

IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis,

major breakpoint region (MBR) and minor cluster region (mcr)

breakpoints, qualitative or quantitative

AIM Guidelines Add effective 01/01/2021

81279 Molecular and Genetic LabJAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted

sequence analysis (eg, exons 12 and 13)AIM Guidelines Add effective 01/01/2021


MPL (MPL proto-oncogene, thrombopoietin receptor) (eg,

myeloproliferative disorder) gene analysis; common variants (eg,

W515A, W515K, W515L, W515R)


81339 Molecular and Genetic LabMPL (MPL proto-oncogene, thrombopoietin receptor) (eg,

myeloproliferative disorder) gene analysis; sequence analysis, exon 10AIM Guidelines Add effective 01/01/2021

PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.

2021 Commercial Outpatient Benefit Preauthorization Fully Insured

Medical Surgical Procedure Code List

This list is not exhaustive. Codes may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit

booklet, or contact a customer service representative to determine coverage for a specific medical service or supply.

The following care categories require preauthorization through AIM for all Commercial members:

Molecular and Genomic Tests

Radiation Therapy

Advanced Imaging

Musculoskeletal - Pain Management

Musculoskeletal - Joint and Spine Surgery

Utilizing the AIM Healthcare Web Portal is the most efficient way tot initaite a

case, check status, review guidelines, view authroziation/eigibility and more.

Web portal available 24/7.

URL: https://aimspecialtyhealth.com

Or call toll-free at 1-866-745-1789 between 7 a.m. and 7 p.m.

Monday through Friday except holidays.

The following outpatient care categories may require preauthorization for Commercial - Fully Insured members:

Molecular and Genomic Tests (AIM)

Radiation Therapy (AIM)

Advanced Imaging (AIM)

Musculoskeletal - Pain Management (AIM)

Musculoskeletal - Joint and Spine Surgery (AIM)

Select Outpatient Procedures (see code list below)

Ear, Nose and Throat (ENT)

Gastroenterology

Musculoskeletal

Neurology

Outpatient Surgery - Orthognathic Surgery (face reconstruction)

Outpatient Surgery - Mastopexy (breast lift)

Outpatient Surgery - Reduction Mammaplasty (breast reduction)

Sleep Studies

Wound Care

ALL Services listed in Section 10.2 of the Provider Reference Manual, including ALL inpatient services

Note: Specialty Pharmacy & Behavioral Health PA codes are also provided for review/download on separate lists.

The following list of outpatient procedure codes may require preauthorization for commercial members. This list is not exhaustive. Codes may be updated throughout the year. The presence of codes on this list does not necessarily indicate

coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply.

11/2020 Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX.

ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE..


SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic

syndrome/acute myeloid leukemia) gene analysis, common variants

(eg, A672T, E622D, L833F, R625C, R625L)



SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic

syndrome, acute myeloid leukemia) gene analysis, common variants

(eg, P95H, P95L)


81351 Molecular and Genetic LabTP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis;

full gene sequenceAIM Guidelines Add effective 01/01/2021


targeted sequence analysis (eg, 4 oncology)AIM Guidelines Add effective 01/01/2021


known familial variantAIM Guidelines Add effective 01/01/2021


U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic

syndrome, acute myeloid leukemia) gene analysis, common variants

(eg, S34F, S34Y, Q157R, Q157P)



ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-

rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene

analysis, common variant(s) (eg, E65fs, E122fs, R448fs)



Epilepsy genomic sequence analysis panel, must include analyses for

ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2,

MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A,

SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, and ZEB2



Oncology (cutaneous melanoma), mRNA, gene expression profiling by

real-time RT-PCR of 31 genes (28 content and 3 housekeeping),

utilizing formalin-fixed paraffin-embedded tissue, algorithm reported

as recurrence risk, including likelihood of sentinel lymph node

metastasis



Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes,

utilizing fine needle aspirate, algorithm reported as a categorical

result (eg, benign or suspicious)



Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene

expression analysis of 190 genes, utilizing transbronchial biopsies,

diagnostic algorithm reported as categorical result (eg, positive or

negative for high probability of usual interstitial pneumonia [UIP])


0016M Molecular and Genetic Lab

Oncology (bladder), mRNA, microarray gene expression profiling of

209 genes, utilizing formalinfixed paraffin-embedded tissue,

algorithm reported as molecular subtype (luminal, luminal infiltrated,

basal, basal claudin-low, neuroendocrine-like)


0104U Molecular and Genetic Lab

Hereditary pan cancer (eg, hereditary breast and ovarian cancer,

hereditary endometrial cancer, hereditary colorectal cancer), genomic

sequence analysis panel utilizing a combination of NGS, Sanger,

MLPA, and array CGH, with MRNA analytics to resolve variants of

unknown significance when indicated (32 genes sequencing and

deletion/duplication], EPCAM and GREM1 [deletion/duplication only])


0203U Molecular and Genetic Lab AI IBD MRNA XPRSN PRFL 17 _ AIM Guidelines Add effective 01/01/2021

0204U Molecular and Genetic Lab ONC THYR MRNA XPRSN ALYS 593 _ AIM Guidelines Add effective 01/01/2021

0205U Molecular and Genetic Lab OPH AMD ALYS 3 GENE VARIANTS _ AIM Guidelines Add effective 01/01/2021

0208U Molecular and Genetic Lab ONC MTC MRNA XPRSN ALYS 108 _ AIM Guidelines Add effective 01/01/2021

0209U Molecular and Genetic Lab CYTOG CONST ALYS INTERROG _ AIM Guidelines Add effective 01/01/2021

0211U Molecular and Genetic Lab ONC PAN-TUM DNA&RNA GNRJ SEQ _ AIM Guidelines Add effective 01/01/2021

0212U Molecular and Genetic Lab RARE DS GEN DNA ALYS PROBAND _ AIM Guidelines Add effective 01/01/2021

0213U Molecular and Genetic Lab RARE DS GEN DNA ALYS EA COMP _ AIM Guidelines Add effective 01/01/2021

0214U Molecular and Genetic Lab RARE DS XOM DNA ALYS PROBAND _ AIM Guidelines Add effective 01/01/2021

0215U Molecular and Genetic Lab RARE DS XOM DNA ALYS EA COMP _ AIM Guidelines Add effective 01/01/2021

0216U Molecular and Genetic Lab NEURO INH ATAXIA DNA 12 COM _ AIM Guidelines Add effective 01/01/2021

0217U Molecular and Genetic Lab NEURO INH ATAXIA DNA 51 GENE _ AIM Guidelines Add effective 01/01/2021


Neurology (muscular dystrophy), DMD gene sequence analysis,

including small sequence changes, deletions, duplications, and

variants in non-uniquely mappable regions, blood or saliva,

identification and characterization of genetic variants



Oncology (prostate), multianalyte molecular profile by photometric

detection of macromolecules adsorbed on nanosponge array slides

with machine learning, utilizing first morning voided urine, algorithm

reported as likelihood of prostate cancer

_ AIM Guidelines Add effective 01/01/2021


BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS

family zinc finger 1) (eg, colorectal cancer) promoter methylation

analysis


11/2020 2021 Commercial Medical Surgical Fully Insured PA Code List Page 2 / 16




AR (androgen receptor) (eg, spinal and bulbar muscular atrophy,

Kennedy disease, X chromosome inactivation), full sequence analysis,

including small sequence changes in exonic and intronic regions,

deletions, duplications, short tandem repeat (STR) expansions, mobile

element insertions, and variants in non-uniquely mappable regions



CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg,

spinocerebellar ataxia), full gene analysis, including small sequence

changes in exonic and intronic regions, deletions, duplications, short

tandem repeat (STR) gene expansions, mobile element insertions, and

variants in non-uniquely mappable regions



CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A,

Unverricht-Lundborg disease), full gene analysis, including small

sequence changes in exonic and intronic regions, deletions,

duplications, short tandem repeat (STR) expansions, mobile element

insertions, and variants in non-uniquely mappable regions



FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small


duplications, short tandem repeat (STR) expansions, mobile element

insertions, and variants in non-uniquely mappable regions



MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene

analysis, including small sequence changes in exonic and intronic

regions, deletions, duplications, mobile element insertions, and




PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome,

PTEN hamartoma tumor syndrome), full gene analysis, including small


duplications, mobile element insertions, and variants in non-uniquely

mappable regions



SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of

motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene

analysis, including small sequence changes in exonic and intronic

regions, duplications and deletions, and mobile element insertions



Cardiac ion channelopathies (eg, Brugada syndrome, long QT

syndrome, short QT syndrome, catecholaminergic polymorphic

ventricular tachycardia), genomic sequence analysis panel including

ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2,

and SCN5A, including small sequence changes in exonic and intronic

regions, deletions, duplications, mobile element insertions, and




Oncology (Lynch syndrome), genomic DNA sequence analysis of

MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence

changes in exonic and intronic regions, deletions, duplications, mobile

element insertions, and variants in non-uniquely mappable regions



Targeted genomic sequence analysis panel, solid organ neoplasm, cell-

free DNA, analysis of 311 or more genes, interrogation for sequence

variants, including substitutions, insertions, deletions, select

rearrangements, and copy number variations


0172U Molecular and Genetic Lab ONC SLD TUM ALYS BRCA1 BRCA2 _ AIM Guidelines Retired 01/01/2021

0173U Molecular and Genetic Lab PEANUT ALLG SPEC ASMT 64 EPI _ AIM Guidelines Retired 01/01/2021

0175U Molecular and Genetic Lab PSYC GEN ALYS PANEL 15 GENES _ AIM Guidelines Retired 01/01/2021

0179U Molecular and Genetic Lab ONC NONSM CLL LNG CA ALYS 23 _ AIM Guidelines Retired 01/01/2021

15824 Select Outpatient Services REMOVAL OF FOREHEAD WRINKLES SUR712.031Surgical Deactivation of Headache

Trigger Sites_

15826 Select Outpatient Services REMOVAL OF BROW WRINKLES SUR712.031Surgical Deactivation of Headache

Trigger Sites_

19316 Select Outpatient Services SUSPENSION OF BREAST SUR716.010 Mastopexy _

19318 Select Outpatient Services REDUCTION OF LARGE BREAST SUR716.012 Reduction Mammaplasty _

20930 Joint, Spine Surgery SP BONE ALGRFT MORSEL ADD-ON _ AIM Guidelines _

20931 Joint, Spine Surgery SP BONE ALGRFT STRUCT ADD-ON _ AIM Guidelines _

20936 Joint, Spine Surgery SP BONE AGRFT LOCAL ADD-ON _ AIM Guidelines _

20937 Joint, Spine Surgery SP BONE AGRFT MORSEL ADD-ON _ AIM Guidelines _

20938 Joint, Spine Surgery SP BONE AGRFT STRUCT ADD-ON _ AIM Guidelines _

20974 Joint, Spine Surgery ELECTRICAL BONE STIMULATION _ AIM Guidelines _

20975 Joint, Spine Surgery ELECTRICAL BONE STIMULATION _ AIM Guidelines _

21085 Select Outpatient Services PREPARE FACE/ORAL PROSTHESIS SUR705.030 Orthognathic Surgery _

21110 Select Outpatient Services INTERDENTAL FIXATION SUR705.030 Orthognathic Surgery _

21125 Select Outpatient Services AUGMENTATION LOWER JAW BONE SUR705.030 Orthognathic Surgery _

21127 Select Outpatient Services AUGMENTATION LOWER JAW BONE SUR705.030 Orthognathic Surgery _

21141 Select Outpatient Services LEFORT I-1 PIECE W/O GRAFT SUR705.030 Orthognathic Surgery _

21142 Select Outpatient Services LEFORT I-2 PIECE W/O GRAFT SUR705.030 Orthognathic Surgery _

21143 Select Outpatient Services LEFORT I-3/> PIECE W/O GRAFT SUR705.030 Orthognathic Surgery _

21145 Select Outpatient Services LEFORT I-1 PIECE W/ GRAFT SUR705.030 Orthognathic Surgery _

21146 Select Outpatient Services LEFORT I-2 PIECE W/ GRAFT SUR705.030 Orthognathic Surgery _

21147 Select Outpatient Services LEFORT I-3/> PIECE W/ GRAFT SUR705.030 Orthognathic Surgery _

21150 Select Outpatient Services LEFORT II ANTERIOR INTRUSION SUR705.030 Orthognathic Surgery _

21151 Select Outpatient Services LEFORT II W/BONE GRAFTS SUR705.030 Orthognathic Surgery _

21154 Select Outpatient Services LEFORT III W/O LEFORT I SUR705.030 Orthognathic Surgery _




21155 Select Outpatient Services LEFORT III W/ LEFORT I SUR705.030 Orthognathic Surgery _

21159 Select Outpatient Services LEFORT III W/FHDW/O LEFORT I SUR705.030 Orthognathic Surgery _

21160 Select Outpatient Services LEFORT III W/FHD W/ LEFORT I SUR705.030 Orthognathic Surgery _

21188 Select Outpatient Services RECONSTRUCTION OF MIDFACE SUR705.030 Orthognathic Surgery _

21193 Select Outpatient Services RECONST LWR JAW W/O GRAFT SUR705.030 Orthognathic Surgery _

21194 Select Outpatient Services RECONST LWR JAW W/GRAFT SUR705.030 Orthognathic Surgery _

21195 Select Outpatient Services RECONST LWR JAW W/O FIXATION SUR705.030 Orthognathic Surgery _

21196 Select Outpatient Services RECONST LWR JAW W/FIXATION SUR705.030 Orthognathic Surgery _

21198 Select Outpatient Services RECONSTR LWR JAW SEGMENT SUR705.030 Orthognathic Surgery _

21199 Select Outpatient Services RECONSTR LWR JAW W/ADVANCE SUR705.030 Orthognathic Surgery _

21206 Select Outpatient Services RECONSTRUCT UPPER JAW BONE SUR705.030 Orthognathic Surgery _

21208 Select Outpatient Services AUGMENTATION OF FACIAL BONES SUR705.030 Orthognathic Surgery _

21209 Select Outpatient Services REDUCTION OF FACIAL BONES SUR705.030 Orthognathic Surgery _

21210 Select Outpatient Services FACE BONE GRAFT SUR705.030 Orthognathic Surgery _

21215 Select Outpatient Services LOWER JAW BONE GRAFT SUR705.030 Orthognathic Surgery _

21230 Select Outpatient Services RIB CARTILAGE GRAFT SUR705.030 Orthognathic Surgery _

22510 Joint, Spine Surgery PERQ CERVICOTHORACIC INJECT _ AIM Guidelines _

22511 Joint, Spine Surgery PERQ LUMBOSACRAL INJECTION _ AIM Guidelines _

22512 Joint, Spine Surgery VERTEBROPLASTY ADDL INJECT _ AIM Guidelines _

22513 Joint, Spine Surgery PERQ VERTEBRAL AUGMENTATION _ AIM Guidelines _



22526 Pain Management IDET SINGLE LEVEL _ AIM Guidelines _

22527 Pain Management IDET 1 OR MORE LEVELS _ AIM Guidelines _

22533 Joint, Spine Surgery LAT LUMBAR SPINE FUSION _ AIM Guidelines _

22534 Joint, Spine Surgery LAT THOR/LUMB ADDL SEG _ AIM Guidelines _

22551 Joint, Spine Surgery NECK SPINE FUSE&REMOV BEL C2 _ AIM Guidelines _

22552 Joint, Spine Surgery ADDL NECK SPINE FUSION _ AIM Guidelines _

22554 Joint, Spine Surgery NECK SPINE FUSION _ AIM Guidelines _

22558 Joint, Spine Surgery LUMBAR SPINE FUSION _ AIM Guidelines _

22585 Joint, Spine Surgery ADDITIONAL SPINAL FUSION _ AIM Guidelines _

22595 Joint, Spine Surgery NECK SPINAL FUSION _ AIM Guidelines _

22600 Joint, Spine Surgery NECK SPINE FUSION _ AIM Guidelines _


22614 Joint, Spine Surgery SPINE FUSION EXTRA SEGMENT _ AIM Guidelines _



22633 Joint, Spine Surgery LUMBAR SPINE FUSION COMBINED _ AIM Guidelines _


22840 Joint, Spine Surgery INSERT SPINE FIXATION DEVICE _ AIM Guidelines _








22848 Joint, Spine Surgery INSERT PELV FIXATION DEVICE _ AIM Guidelines _

22853 Joint, Spine Surgery INSJ BIOMECHANICAL DEVICE _ AIM Guidelines _


22856 Joint, Spine Surgery CERV ARTIFIC DISKECTOMY _ AIM Guidelines _

22857 Joint, Spine Surgery LUMBAR ARTIF DISKECTOMY _ AIM Guidelines _

22858 Joint, Spine Surgery SECOND LEVEL CER DISKECTOMY _ AIM Guidelines _


22861 Joint, Spine Surgery REVISE CERV ARTIFIC DISC _ AIM Guidelines _

22862 Joint, Spine Surgery REVISE LUMBAR ARTIF DISC _ AIM Guidelines _

22867 Joint, Spine Surgery INSJ STABLJ DEV W/DCMPRN _ AIM Guidelines _

22868 Joint, Spine Surgery INSJ STABLJ DEV W/DCMPRN _ AIM Guidelines _

22869 Joint, Spine Surgery INSJ STABLJ DEV W/O DCMPRN _ AIM Guidelines _

22870 Joint, Spine Surgery INSJ STABLJ DEV W/O DCMPRN _ AIM Guidelines _

23000 Joint, Spine Surgery REMOVAL OF CALCIUM DEPOSITS _ AIM Guidelines _

23020 Joint, Spine Surgery RELEASE SHOULDER JOINT _ AIM Guidelines _

23120 Joint, Spine Surgery PARTIAL REMOVAL COLLAR BONE _ AIM Guidelines _

23130 Joint, Spine Surgery REMOVE SHOULDER BONE PART _ AIM Guidelines _

23410 Joint, Spine Surgery REPAIR ROTATOR CUFF ACUTE _ AIM Guidelines _

23412 Joint, Spine Surgery REPAIR ROTATOR CUFF CHRONIC _ AIM Guidelines _

23415 Joint, Spine Surgery RELEASE OF SHOULDER LIGAMENT _ AIM Guidelines _

23420 Joint, Spine Surgery REPAIR OF SHOULDER _ AIM Guidelines _

23430 Joint, Spine Surgery REPAIR BICEPS TENDON _ AIM Guidelines _

23440 Joint, Spine Surgery REMOVE/TRANSPLANT TENDON _ AIM Guidelines _

23450 Joint, Spine Surgery REPAIR SHOULDER CAPSULE _ AIM Guidelines _






23470 Joint, Spine Surgery RECONSTRUCT SHOULDER JOINT _ AIM Guidelines _

23472 Joint, Spine Surgery RECONSTRUCT SHOULDER JOINT _ AIM Guidelines _

23473 Joint, Spine Surgery REVIS RECONST SHOULDER JOINT _ AIM Guidelines _

23474 Joint, Spine Surgery REVIS RECONST SHOULDER JOINT _ AIM Guidelines _

27096 Pain Management INJECT SACROILIAC JOINT _ AIM Guidelines _




27125 Joint, Spine Surgery PARTIAL HIP REPLACEMENT _ AIM Guidelines _

27130 Joint, Spine Surgery TOTAL HIP ARTHROPLASTY _ AIM Guidelines _

27132 Joint, Spine Surgery TOTAL HIP ARTHROPLASTY _ AIM Guidelines _

27134 Joint, Spine Surgery REVISE HIP JOINT REPLACEMENT _ AIM Guidelines _



27279 Joint, Spine Surgery ARTHRODESIS SACROILIAC JOINT _ AIM Guidelines _

27280 Joint, Spine Surgery FUSION OF SACROILIAC JOINT _ AIM Guidelines _

27332 Joint, Spine Surgery REMOVAL OF KNEE CARTILAGE _ AIM Guidelines _

27333 Joint, Spine Surgery REMOVAL OF KNEE CARTILAGE _ AIM Guidelines _

27334 Joint, Spine Surgery REMOVE KNEE JOINT LINING _ AIM Guidelines _

27335 Joint, Spine Surgery REMOVE KNEE JOINT LINING _ AIM Guidelines _

27403 Joint, Spine Surgery REPAIR OF KNEE CARTILAGE _ AIM Guidelines _

27412 Joint, Spine Surgery AUTOCHONDROCYTE IMPLANT KNEE _ AIM Guidelines _

27415 Joint, Spine Surgery OSTEOCHONDRAL KNEE ALLOGRAFT _ AIM Guidelines _

27416 Joint, Spine Surgery OSTEOCHONDRAL KNEE AUTOGRAFT _ AIM Guidelines _

27418 Joint, Spine Surgery REPAIR DEGENERATED KNEECAP _ AIM Guidelines _

27420 Joint, Spine Surgery REVISION OF UNSTABLE KNEECAP _ AIM Guidelines _

27422 Joint, Spine Surgery REVISION OF UNSTABLE KNEECAP _ AIM Guidelines _

27424 Joint, Spine Surgery REVISION/REMOVAL OF KNEECAP _ AIM Guidelines _

27425 Joint, Spine Surgery LAT RETINACULAR RELEASE OPEN _ AIM Guidelines _

27427 Joint, Spine Surgery RECONSTRUCTION KNEE _ AIM Guidelines _



27430 Joint, Spine Surgery REVISION OF THIGH MUSCLES _ AIM Guidelines _

27438 Joint, Spine Surgery REVISE KNEECAP WITH IMPLANT _ AIM Guidelines _

27440 Joint, Spine Surgery REVISION OF KNEE JOINT _ AIM Guidelines _





27447 Joint, Spine Surgery TOTAL KNEE ARTHROPLASTY _ AIM Guidelines _

27486 Joint, Spine Surgery REVISE/REPLACE KNEE JOINT _ AIM Guidelines _

27487 Joint, Spine Surgery REVISE/REPLACE KNEE JOINT _ AIM Guidelines _

30120 Select Outpatient Services REVISION OF NOSE SUR706.001 Nasal and Sinus Surgery _

30124 Select Outpatient Services REMOVAL OF NOSE LESION N/A Nasal and Sinus Surgery _

30130 Select Outpatient Services EXCISE INFERIOR TURBINATE SUR712.031Surgical Deactivation of Headache

Trigger Sites_

30140 Select Outpatient Services RESECT INFERIOR TURBINATE SUR712.031Surgical Deactivation of Headache

Trigger Sites_

30400 Select Outpatient Services RECONSTRUCTION OF NOSE SUR706.001 Nasal and Sinus Surgery _






30465 Select Outpatient Services REPAIR NASAL STENOSIS N/A Nasal and Sinus Surgery _

30520 Select Outpatient Services REPAIR OF NASAL SEPTUM SUR712.031Surgical Deactivation of Headache

Trigger Sites_

30999 Select Outpatient Services NASAL SURGERY PROCEDURE SUR706.001 Nasal and Sinus Surgery _

31296 Select Outpatient Services NSL/SINS NDSC SURG FRNT SINS SUR706.001 Nasal and Sinus Surgery _

31297 Select Outpatient Services NSL/SINS NDSC SURG SPHN SINS SUR706.001 Nasal and Sinus Surgery _

31299 Select Outpatient Services SINUS SURGERY PROCEDURE SUR706.001 Nasal and Sinus Surgery _

36516 Select Outpatient Services THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION THE802.003 Lipid Apheresis _

38206 Select Outpatient Services HARVEST AUTO STEM CELLS SUR703.051Orthopedic Applications of Stem-Cell

Therapy_

38230 Select Outpatient Services BONE MARROW HARVEST ALLOGEN SUR703.051Orthopedic Applications of Stem-Cell

Therapy_

38241 Select Outpatient Services TRANSPLT AUTOL HCT/DONOR SUR703.051Orthopedic Applications of Stem-Cell

Therapy_

43647 Select Outpatient Services LAP IMPL ELECTRODE ANTRUM SUR709.031 Gastric Electrical Stimulation (GES) _

43648 Select Outpatient Services LAP REVISE/REMV ELTRD ANTRUM SUR709.031 Gastric Electrical Stimulation (GES) _

43881 Select Outpatient Services IMPL/REDO ELECTRD ANTRUM SUR709.031 Gastric Electrical Stimulation (GES) _

61850 Select Outpatient Services IMPLANT NEUROELECTRODES SUR712.025 Deep Brain Stimulation _

61863 Select Outpatient Services IMPLANT NEUROELECTRODE SUR712.025 Deep Brain Stimulation _

61864 Select Outpatient Services IMPLANT NEUROELECTRDE ADDL SUR712.025 Deep Brain Stimulation _

61867 Select Outpatient Services IMPLANT NEUROELECTRODE SUR712.025 Deep Brain Stimulation _

61868 Select Outpatient Services IMPLANT NEUROELECTRDE ADDL SUR712.025 Deep Brain Stimulation _

62263 Pain Management EPIDURAL LYSIS MULT SESSIONS _ AIM Guidelines _

62264 Pain Management EPIDURAL LYSIS ON SINGLE DAY _ AIM Guidelines _

62280 Pain Management TREAT SPINAL CORD LESION _ AIM Guidelines _

62281 Pain Management TREAT SPINAL CORD LESION _ AIM Guidelines _

62282 Pain Management TREAT SPINAL CANAL LESION _ AIM Guidelines _

62287 Pain Management PERCUTANEOUS DISKECTOMY _ AIM Guidelines _

62292 Pain Management NJX CHEMONUCLEOLYSIS LMBR _ AIM Guidelines _

62320 Pain Management NJX INTERLAMINAR CRV/THRC _ AIM Guidelines _


62322 Pain Management NJX INTERLAMINAR LMBR/SAC _ AIM Guidelines _









62350 Pain Management IMPLANT SPINAL CANAL CATH _ AIM Guidelines _

62351 Pain Management IMPLANT SPINAL CANAL CATH _ AIM Guidelines _

62360 Pain Management INSERT SPINE INFUSION DEVICE _ AIM Guidelines _

62361 Pain Management IMPLANT SPINE INFUSION PUMP _ AIM Guidelines _

62362 Pain Management IMPLANT SPINE INFUSION PUMP _ AIM Guidelines _

62380 Joint, Spine Surgery NDSC DCMPRN 1 NTRSPC LUMBAR _ AIM Guidelines _

63001 Joint, Spine Surgery REMOVE SPINE LAMINA 1/2 CRVL _ AIM Guidelines _

63005 Joint, Spine Surgery REMOVE SPINE LAMINA 1/2 LMBR _ AIM Guidelines _

63012 Joint, Spine Surgery REMOVE LAMINA/FACETS LUMBAR _ AIM Guidelines _

63015 Joint, Spine Surgery REMOVE SPINE LAMINA >2 CRVCL _ AIM Guidelines _

63017 Joint, Spine Surgery REMOVE SPINE LAMINA >2 LMBR _ AIM Guidelines _

63020 Joint, Spine Surgery NECK SPINE DISK SURGERY _ AIM Guidelines _

63030 Joint, Spine Surgery LOW BACK DISK SURGERY _ AIM Guidelines _

63035 Joint, Spine Surgery SPINAL DISK SURGERY ADD-ON _ AIM Guidelines _

63040 Joint, Spine Surgery LAMINOTOMY SINGLE CERVICAL _ AIM Guidelines _

63042 Joint, Spine Surgery LAMINOTOMY SINGLE LUMBAR _ AIM Guidelines _

63043 Joint, Spine Surgery LAMINOTOMY ADDL CERVICAL _ AIM Guidelines _

63044 Joint, Spine Surgery LAMINOTOMY ADDL LUMBAR _ AIM Guidelines _

63045 Joint, Spine Surgery REMOVE SPINE LAMINA 1 CRVL _ AIM Guidelines _

63047 Joint, Spine Surgery REMOVE SPINE LAMINA 1 LMBR _ AIM Guidelines _

63048 Joint, Spine Surgery REMOVE SPINAL LAMINA ADD-ON _ AIM Guidelines _

63050 Joint, Spine Surgery CERVICAL LAMINOPLSTY 2/> SEG _ AIM Guidelines _

63051 Joint, Spine Surgery C-LAMINOPLASTY W/GRAFT/PLATE _ AIM Guidelines _

63056 Joint, Spine Surgery DECOMPRESS SPINAL CORD LMBR _ AIM Guidelines _

63057 Joint, Spine Surgery DECOMPRESS SPINE CORD ADD-ON _ AIM Guidelines _



63081 Joint, Spine Surgery REMOVE VERT BODY DCMPRN CRVL _ AIM Guidelines _

63082 Joint, Spine Surgery REMOVE VERTEBRAL BODY ADD-ON _ AIM Guidelines _

63650 Pain Management IMPLANT NEUROELECTRODES _ AIM Guidelines _

63655 Pain Management IMPLANT NEUROELECTRODES _ AIM Guidelines _

63685 Pain Management INSRT/REDO SPINE N GENERATOR _ AIM Guidelines _

64451 Pain Management NJX AA&/STRD NRV NRVTG SI JT _ AIM Guidelines _

64479 Pain Management INJ FORAMEN EPIDURAL C/T _ AIM Guidelines _

64480 Pain Management INJ FORAMEN EPIDURAL ADD-ON _ AIM Guidelines _

64483 Pain Management INJ FORAMEN EPIDURAL L/S _ AIM Guidelines _

64484 Pain Management INJ FORAMEN EPIDURAL ADD-ON _ AIM Guidelines _

64490 Pain Management INJ PARAVERT F JNT C/T 1 LEV _ AIM Guidelines _



64493 Pain Management INJ PARAVERT F JNT L/S 1 LEV _ AIM Guidelines _



64510 Pain Management N BLOCK STELLATE GANGLION _ AIM Guidelines _

64520 Pain Management N BLOCK LUMBAR/THORACIC _ AIM Guidelines _

64561 Select Outpatient Services IMPLANT NEUROELECTRODES SUR710.018Sacral Nerve

Neuromodulation/Stimulation_

64581 Select Outpatient Services IMPLANT NEUROELECTRODES SUR710.018Sacral Nerve


64625 Pain Management RF ABLTJ NRV NRVTG SI JT _ AIM Guidelines _

64633 Pain Management DESTROY CERV/THOR FACET JNT _ AIM Guidelines _

64634 Pain Management DESTROY C/TH FACET JNT ADDL _ AIM Guidelines _

64635 Pain Management DESTROY LUMB/SAC FACET JNT _ AIM Guidelines _

64636 Pain Management DESTROY L/S FACET JNT ADDL _ AIM Guidelines _

64716 Select Outpatient Services REVISION OF CRANIAL NERVE SUR712.031Surgical Deactivation of Headache

Trigger Sites_

64732 Select Outpatient Services INCISION OF BROW NERVE SUR712.031Surgical Deactivation of Headache

Trigger Sites_

64734 Select Outpatient Services INCISION OF CHEEK NERVE SUR712.031Surgical Deactivation of Headache

Trigger Sites_

64771 Select Outpatient Services SEVER CRANIAL NERVE SUR712.031Surgical Deactivation of Headache

Trigger Sites_

64999 Select Outpatient Services NERVOUS SYSTEM SURGERY SUR712.031Surgical Deactivation of Headache

Trigger Sites_

67900 Select Outpatient Services REPAIR BROW DEFECT SUR712.031Surgical Deactivation of Headache

Trigger Sites_

69714 Select Outpatient Services IMPLANT TEMPLE BONE W/STIMUL SUR714.003 Bone Conduction Hearing Aids _

69715 Select Outpatient Services TEMPLE BNE IMPLNT W/STIMULAT SUR714.003 Bone Conduction Hearing Aids _

69717 Select Outpatient Services TEMPLE BONE IMPLANT REVISION SUR714.003 Bone Conduction Hearing Aids _

69718 Select Outpatient Services REVISE TEMPLE BONE IMPLANT SUR714.003 Bone Conduction Hearing Aids _

69930 Select Outpatient Services IMPLANT COCHLEAR DEVICE SUR714.004 Cochlear Implant _

70336 Advanced Imaging MAGNETIC IMAGE JAW JOINT _ AIM Guidelines _

70450 Advanced Imaging CT HEAD/BRAIN W/O DYE _ AIM Guidelines _

70460 Advanced Imaging CT HEAD/BRAIN W/DYE _ AIM Guidelines _

70470 Advanced Imaging CT HEAD/BRAIN W/O & W/DYE _ AIM Guidelines _

70480 Advanced Imaging CT ORBIT/EAR/FOSSA W/O DYE _ AIM Guidelines _

70481 Advanced Imaging CT ORBIT/EAR/FOSSA W/DYE _ AIM Guidelines _

70482 Advanced Imaging CT ORBIT/EAR/FOSSA W/O&W/DYE _ AIM Guidelines _

70486 Advanced Imaging CT MAXILLOFACIAL W/O DYE _ AIM Guidelines _

70487 Advanced Imaging CT MAXILLOFACIAL W/DYE _ AIM Guidelines _




70488 Advanced Imaging CT MAXILLOFACIAL W/O & W/DYE _ AIM Guidelines _

70490 Advanced Imaging CT SOFT TISSUE NECK W/O DYE _ AIM Guidelines _

70491 Advanced Imaging CT SOFT TISSUE NECK W/DYE _ AIM Guidelines _

70492 Advanced Imaging CT SFT TSUE NCK W/O & W/DYE _ AIM Guidelines _

70496 Advanced Imaging CT ANGIOGRAPHY HEAD _ AIM Guidelines _

70498 Advanced Imaging CT ANGIOGRAPHY NECK _ AIM Guidelines _

70540 Advanced Imaging MRI ORBIT/FACE/NECK W/O DYE _ AIM Guidelines _

70542 Advanced Imaging MRI ORBIT/FACE/NECK W/DYE _ AIM Guidelines _

70543 Advanced Imaging MRI ORBT/FAC/NCK W/O &W/DYE _ AIM Guidelines _

70544 Advanced Imaging MR ANGIOGRAPHY HEAD W/O DYE _ AIM Guidelines _

70545 Advanced Imaging MR ANGIOGRAPHY HEAD W/DYE _ AIM Guidelines _

70546 Advanced Imaging MR ANGIOGRAPH HEAD W/O&W/DYE _ AIM Guidelines _

70547 Advanced Imaging MR ANGIOGRAPHY NECK W/O DYE _ AIM Guidelines _

70548 Advanced Imaging MR ANGIOGRAPHY NECK W/DYE _ AIM Guidelines _

70549 Advanced Imaging MR ANGIOGRAPH NECK W/O&W/DYE _ AIM Guidelines _

70551 Advanced Imaging MRI BRAIN STEM W/O DYE _ AIM Guidelines _

70552 Advanced Imaging MRI BRAIN STEM W/DYE _ AIM Guidelines _

70553 Advanced Imaging MRI BRAIN STEM W/O & W/DYE _ AIM Guidelines _

70554 Advanced Imaging FMRI BRAIN BY TECH _ AIM Guidelines _

70555 Advanced Imaging FMRI BRAIN BY PHYS/PSYCH _ AIM Guidelines _

71250 Advanced Imaging CT THORAX W/O DYE _ AIM Guidelines _

71260 Advanced Imaging CT THORAX W/DYE _ AIM Guidelines _

71270 Advanced Imaging CT THORAX W/O & W/DYE _ AIM Guidelines _

71275 Advanced Imaging CT ANGIOGRAPHY CHEST _ AIM Guidelines _

71550 Advanced Imaging MRI CHEST W/O DYE _ AIM Guidelines _

71551 Advanced Imaging MRI CHEST W/DYE _ AIM Guidelines _

71552 Advanced Imaging MRI CHEST W/O & W/DYE _ AIM Guidelines _

71555 Advanced Imaging MRI ANGIO CHEST W OR W/O DYE _ AIM Guidelines _

72125 Advanced Imaging CT NECK SPINE W/O DYE _ AIM Guidelines _

72126 Advanced Imaging CT NECK SPINE W/DYE _ AIM Guidelines _

72127 Advanced Imaging CT NECK SPINE W/O & W/DYE _ AIM Guidelines _

72128 Advanced Imaging CT CHEST SPINE W/O DYE _ AIM Guidelines _

72129 Advanced Imaging CT CHEST SPINE W/DYE _ AIM Guidelines _

72130 Advanced Imaging CT CHEST SPINE W/O & W/DYE _ AIM Guidelines _

72131 Advanced Imaging CT LUMBAR SPINE W/O DYE _ AIM Guidelines _

72132 Advanced Imaging CT LUMBAR SPINE W/DYE _ AIM Guidelines _

72133 Advanced Imaging CT LUMBAR SPINE W/O & W/DYE _ AIM Guidelines _

72141 Advanced Imaging MRI NECK SPINE W/O DYE _ AIM Guidelines _

72142 Advanced Imaging MRI NECK SPINE W/DYE _ AIM Guidelines _

72146 Advanced Imaging MRI CHEST SPINE W/O DYE _ AIM Guidelines _

72147 Advanced Imaging MRI CHEST SPINE W/DYE _ AIM Guidelines _

72148 Advanced Imaging MRI LUMBAR SPINE W/O DYE _ AIM Guidelines _

72149 Advanced Imaging MRI LUMBAR SPINE W/DYE _ AIM Guidelines _

72156 Advanced Imaging MRI NECK SPINE W/O & W/DYE _ AIM Guidelines _

72157 Advanced Imaging MRI CHEST SPINE W/O & W/DYE _ AIM Guidelines _

72158 Advanced Imaging MRI LUMBAR SPINE W/O & W/DYE _ AIM Guidelines _

72159 Advanced Imaging MR ANGIO SPINE W/O&W/DYE _ AIM Guidelines _

72191 Advanced Imaging CT ANGIOGRAPH PELV W/O&W/DYE _ AIM Guidelines _

72192 Advanced Imaging CT PELVIS W/O DYE _ AIM Guidelines _

72193 Advanced Imaging CT PELVIS W/DYE _ AIM Guidelines _

72194 Advanced Imaging CT PELVIS W/O & W/DYE _ AIM Guidelines _

72195 Advanced Imaging MRI PELVIS W/O DYE _ AIM Guidelines _

72196 Advanced Imaging MRI PELVIS W/DYE _ AIM Guidelines _

72197 Advanced Imaging MRI PELVIS W/O & W/DYE _ AIM Guidelines _

72198 Advanced Imaging MR ANGIO PELVIS W/O & W/DYE _ AIM Guidelines _

73200 Advanced Imaging CT UPPER EXTREMITY W/O DYE _ AIM Guidelines _

73201 Advanced Imaging CT UPPER EXTREMITY W/DYE _ AIM Guidelines _

73202 Advanced Imaging CT UPPR EXTREMITY W/O&W/DYE _ AIM Guidelines _

73206 Advanced Imaging CT ANGIO UPR EXTRM W/O&W/DYE _ AIM Guidelines _

73218 Advanced Imaging MRI UPPER EXTREMITY W/O DYE _ AIM Guidelines _

73219 Advanced Imaging MRI UPPER EXTREMITY W/DYE _ AIM Guidelines _

73220 Advanced Imaging MRI UPPR EXTREMITY W/O&W/DYE _ AIM Guidelines _

73221 Advanced Imaging MRI JOINT UPR EXTREM W/O DYE _ AIM Guidelines _

73222 Advanced Imaging MRI JOINT UPR EXTREM W/DYE _ AIM Guidelines _

73223 Advanced Imaging MRI JOINT UPR EXTR W/O&W/DYE _ AIM Guidelines _

73225 Advanced Imaging MR ANGIO UPR EXTR W/O&W/DYE _ AIM Guidelines _

73700 Advanced Imaging CT LOWER EXTREMITY W/O DYE _ AIM Guidelines _

73701 Advanced Imaging CT LOWER EXTREMITY W/DYE _ AIM Guidelines _

73702 Advanced Imaging CT LWR EXTREMITY W/O&W/DYE _ AIM Guidelines _

73706 Advanced Imaging CT ANGIO LWR EXTR W/O&W/DYE _ AIM Guidelines _

73718 Advanced Imaging MRI LOWER EXTREMITY W/O DYE _ AIM Guidelines _

73719 Advanced Imaging MRI LOWER EXTREMITY W/DYE _ AIM Guidelines _

73720 Advanced Imaging MRI LWR EXTREMITY W/O&W/DYE _ AIM Guidelines _

73721 Advanced Imaging MRI JNT OF LWR EXTRE W/O DYE _ AIM Guidelines _

73722 Advanced Imaging MRI JOINT OF LWR EXTR W/DYE _ AIM Guidelines _

73723 Advanced Imaging MRI JOINT LWR EXTR W/O&W/DYE _ AIM Guidelines _

73725 Advanced Imaging MR ANG LWR EXT W OR W/O DYE _ AIM Guidelines _

74150 Advanced Imaging CT ABDOMEN W/O DYE _ AIM Guidelines _

74160 Advanced Imaging CT ABDOMEN W/DYE _ AIM Guidelines _

74170 Advanced Imaging CT ABDOMEN W/O & W/DYE _ AIM Guidelines _

74174 Advanced Imaging CT ANGIO ABD&PELV W/O&W/DYE _ AIM Guidelines _




74175 Advanced Imaging CT ANGIO ABDOM W/O & W/DYE _ AIM Guidelines _

74176 Advanced Imaging CT ABD & PELVIS W/O CONTRAST _ AIM Guidelines _

74177 Advanced Imaging CT ABD & PELV W/CONTRAST _ AIM Guidelines _

74178 Advanced Imaging CT ABD & PELV 1/> REGNS _ AIM Guidelines _

74181 Advanced Imaging MRI ABDOMEN W/O DYE _ AIM Guidelines _

74182 Advanced Imaging MRI ABDOMEN W/DYE _ AIM Guidelines _

74183 Advanced Imaging MRI ABDOMEN W/O & W/DYE _ AIM Guidelines _

74185 Advanced Imaging MRI ANGIO ABDOM W ORW/O DYE _ AIM Guidelines _

74261 Advanced Imaging CT COLONOGRAPHY DX _ AIM Guidelines _

74262 Advanced Imaging CT COLONOGRAPHY DX W/DYE _ AIM Guidelines _

74263 Advanced Imaging CT COLONOGRAPHY SCREENING _ AIM Guidelines _

74712 Advanced Imaging MRI FETAL SNGL/1ST GESTATION _ AIM Guidelines _

74713 Advanced Imaging MRI FETAL EA ADDL GESTATION _ AIM Guidelines _

75635 Advanced Imaging CT ANGIO ABDOMINAL ARTERIES _ AIM Guidelines _

76376 Advanced Imaging 3D RENDER W/INTRP POSTPROCES _ AIM Guidelines _

76377 Advanced Imaging 3D RENDER W/INTRP POSTPROCES _ AIM Guidelines _

76380 Advanced Imaging CAT SCAN FOLLOW-UP STUDY _ AIM Guidelines _

76390 Advanced Imaging MR SPECTROSCOPY _ AIM Guidelines _

76391 Advanced Imaging MR ELASTOGRAPHY _ AIM Guidelines _

76497 Advanced Imaging CT PROCEDURE _ AIM Guidelines _

76498 Advanced Imaging MRI PROCEDURE _ AIM Guidelines _

76975 Advanced Imaging GI ENDOSCOPIC ULTRASOUND _ AIM Guidelines _

77014 Radiation Oncology CT SCAN FOR THERAPY GUIDE _ AIM Guidelines _

77021 Advanced Imaging MRI GUIDANCE NDL PLMT RS&I _ AIM Guidelines _

77022 Advanced Imaging MRI GDN PARNCHYMA TISS ABLTJ _ AIM Guidelines _

77046 Advanced Imaging MRI BREAST C- UNILATERAL _ AIM Guidelines _

77047 Advanced Imaging MRI BREAST C- BILATERAL _ AIM Guidelines _

77048 Advanced Imaging MRI BREAST C-+ W/CAD UNI _ AIM Guidelines _

77049 Advanced Imaging MRI BREAST C-+ W/CAD BI _ AIM Guidelines _

77078 Advanced Imaging CT BONE DENSITY AXIAL _ AIM Guidelines _

77084 Advanced Imaging MAGNETIC IMAGE BONE MARROW _ AIM Guidelines _

77371 Radiation Oncology SRS MULTISOURCE _ AIM Guidelines _

77372 Radiation Oncology SRS LINEAR BASED _ AIM Guidelines _

77373 Radiation Oncology SBRT DELIVERY _ AIM Guidelines _

77385 Radiation Oncology NTSTY MODUL RAD TX DLVR SMPL _ AIM Guidelines _

77386 Radiation Oncology NTSTY MODUL RAD TX DLVR CPLX _ AIM Guidelines _

77387 Radiation Oncology GUIDANCE FOR RADJ TX DLVR _ AIM Guidelines _

77401 Radiation Oncology RADIATION TREATMENT DELIVERY _ AIM Guidelines _




77423 Radiation Oncology NEUTRON BEAM TX COMPLEX _ AIM Guidelines _

77424 Radiation Oncology IO RAD TX DELIVERY BY X-RAY _ AIM Guidelines _

77425 Radiation Oncology IO RAD TX DELIVER BY ELCTRNS _ AIM Guidelines _

77520 Radiation Oncology PROTON TRMT SIMPLE W/O COMP _ AIM Guidelines _

77522 Radiation Oncology PROTON TRMT SIMPLE W/COMP _ AIM Guidelines _

77523 Radiation Oncology PROTON TRMT INTERMEDIATE _ AIM Guidelines _

77525 Radiation Oncology PROTON TREATMENT COMPLEX _ AIM Guidelines _

77600 Radiation Oncology HYPERTHERMIA TREATMENT _ AIM Guidelines _





77750 Radiation Oncology INFUSE RADIOACTIVE MATERIALS _ AIM Guidelines _

77761 Radiation Oncology APPLY INTRCAV RADIAT SIMPLE _ AIM Guidelines _

77762 Radiation Oncology APPLY INTRCAV RADIAT INTERM _ AIM Guidelines _

77763 Radiation Oncology APPLY INTRCAV RADIAT COMPL _ AIM Guidelines _

77767 Radiation Oncology HDR RDNCL SKN SURF BRACHYTX _ AIM Guidelines _

77768 Radiation Oncology HDR RDNCL SKN SURF BRACHYTX _ AIM Guidelines _

77770 Radiation Oncology HDR RDNCL NTRSTL/ICAV BRCHTX _ AIM Guidelines _



77778 Radiation Oncology APPLY INTERSTIT RADIAT COMPL _ AIM Guidelines _

78012 Advanced Imaging THYROID UPTAKE MEASUREMENT _ AIM Guidelines _

78013 Advanced Imaging THYROID IMAGING W/BLOOD FLOW _ AIM Guidelines _

78014 Advanced Imaging THYROID IMAGING W/BLOOD FLOW _ AIM Guidelines _

78015 Advanced Imaging THYROID MET IMAGING _ AIM Guidelines _

78016 Advanced Imaging THYROID MET IMAGING/STUDIES _ AIM Guidelines _

78018 Advanced Imaging THYROID MET IMAGING BODY _ AIM Guidelines _

78020 Advanced Imaging THYROID MET UPTAKE _ AIM Guidelines _

78070 Advanced Imaging PARATHYROID PLANAR IMAGING _ AIM Guidelines _

78071 Advanced Imaging PARATHYRD PLANAR W/WO SUBTRJ _ AIM Guidelines _

78072 Advanced Imaging PARATHYRD PLANAR W/SPECT&CT _ AIM Guidelines _

78075 Advanced Imaging ADRENAL CORTEX & MEDULLA IMG _ AIM Guidelines _

78102 Advanced Imaging BONE MARROW IMAGING LTD _ AIM Guidelines _

78103 Advanced Imaging BONE MARROW IMAGING MULT _ AIM Guidelines _

78104 Advanced Imaging BONE MARROW IMAGING BODY _ AIM Guidelines _

78185 Advanced Imaging SPLEEN IMAGING _ AIM Guidelines _

78195 Advanced Imaging LYMPH SYSTEM IMAGING _ AIM Guidelines _

78201 Advanced Imaging LIVER IMAGING _ AIM Guidelines _

78202 Advanced Imaging LIVER IMAGING WITH FLOW _ AIM Guidelines _




78215 Advanced Imaging LIVER AND SPLEEN IMAGING _ AIM Guidelines _

78216 Advanced Imaging LIVER & SPLEEN IMAGE/FLOW _ AIM Guidelines _

78226 Advanced Imaging HEPATOBILIARY SYSTEM IMAGING _ AIM Guidelines _

78227 Advanced Imaging HEPATOBIL SYST IMAGE W/DRUG _ AIM Guidelines _

78230 Advanced Imaging SALIVARY GLAND IMAGING _ AIM Guidelines _

78231 Advanced Imaging SERIAL SALIVARY IMAGING _ AIM Guidelines _

78232 Advanced Imaging SALIVARY GLAND FUNCTION EXAM _ AIM Guidelines _

78258 Advanced Imaging ESOPHAGEAL MOTILITY STUDY _ AIM Guidelines _

78261 Advanced Imaging GASTRIC MUCOSA IMAGING _ AIM Guidelines _

78262 Advanced Imaging GASTROESOPHAGEAL REFLUX EXAM _ AIM Guidelines _

78264 Advanced Imaging GASTRIC EMPTYING IMAG STUDY _ AIM Guidelines _



78278 Advanced Imaging ACUTE GI BLOOD LOSS IMAGING _ AIM Guidelines _

78290 Advanced Imaging MECKELS DIVERT EXAM _ AIM Guidelines _

78291 Advanced Imaging LEVEEN/SHUNT PATENCY EXAM _ AIM Guidelines _

78300 Advanced Imaging BONE IMAGING LIMITED AREA _ AIM Guidelines _

78305 Advanced Imaging BONE IMAGING MULTIPLE AREAS _ AIM Guidelines _

78306 Advanced Imaging BONE IMAGING WHOLE BODY _ AIM Guidelines _

78315 Advanced Imaging BONE IMAGING 3 PHASE _ AIM Guidelines _

78445 Advanced Imaging VASCULAR FLOW IMAGING _ AIM Guidelines _

78456 Advanced Imaging ACUTE VENOUS THROMBUS IMAGE _ AIM Guidelines _

78457 Advanced Imaging VENOUS THROMBOSIS IMAGING _ AIM Guidelines _

78458 Advanced Imaging VEN THROMBOSIS IMAGES BILAT _ AIM Guidelines _

78579 Advanced Imaging LUNG VENTILATION IMAGING _ AIM Guidelines _

78580 Advanced Imaging LUNG PERFUSION IMAGING _ AIM Guidelines _

78582 Advanced Imaging LUNG VENTILAT&PERFUS IMAGING _ AIM Guidelines _

78597 Advanced Imaging LUNG PERFUSION DIFFERENTIAL _ AIM Guidelines _

78598 Advanced Imaging LUNG PERF&VENTILAT DIFERENTL _ AIM Guidelines _

78600 Advanced Imaging BRAIN IMAGE < 4 VIEWS _ AIM Guidelines _

78601 Advanced Imaging BRAIN IMAGE W/FLOW < 4 VIEWS _ AIM Guidelines _

78605 Advanced Imaging BRAIN IMAGE 4+ VIEWS _ AIM Guidelines _

78606 Advanced Imaging BRAIN IMAGE W/FLOW 4 + VIEWS _ AIM Guidelines _

78608 Advanced Imaging BRAIN IMAGING (PET) _ AIM Guidelines _

78609 Advanced Imaging BRAIN IMAGING (PET) _ AIM Guidelines _

78610 Advanced Imaging BRAIN FLOW IMAGING ONLY _ AIM Guidelines _

78630 Advanced Imaging CEREBROSPINAL FLUID SCAN _ AIM Guidelines _

78635 Advanced Imaging CSF VENTRICULOGRAPHY _ AIM Guidelines _

78645 Advanced Imaging CSF SHUNT EVALUATION _ AIM Guidelines _

78650 Advanced Imaging CSF LEAKAGE IMAGING _ AIM Guidelines _

78660 Advanced Imaging NUCLEAR EXAM OF TEAR FLOW _ AIM Guidelines _

78700 Advanced Imaging KIDNEY IMAGING MORPHOL _ AIM Guidelines _

78701 Advanced Imaging KIDNEY IMAGING WITH FLOW _ AIM Guidelines _

78707 Advanced Imaging K FLOW/FUNCT IMAGE W/O DRUG _ AIM Guidelines _

78708 Advanced Imaging K FLOW/FUNCT IMAGE W/DRUG _ AIM Guidelines _

78709 Advanced Imaging K FLOW/FUNCT IMAGE MULTIPLE _ AIM Guidelines _

78725 Advanced Imaging KIDNEY FUNCTION STUDY _ AIM Guidelines _

78730 Advanced Imaging URINARY BLADDER RETENTION _ AIM Guidelines _

78740 Advanced Imaging URETERAL REFLUX STUDY _ AIM Guidelines _

78761 Advanced Imaging TESTICULAR IMAGING W/FLOW _ AIM Guidelines _

78800 Advanced Imaging RP LOCLZJ TUM 1 AREA 1 D IMG _ AIM Guidelines _

78801 Advanced Imaging RP LOCLZJ TUM 2+AREA 1+D IMG _ AIM Guidelines _

78802 Advanced Imaging RP LOCLZJ TUM WHBDY 1 D IMG _ AIM Guidelines _

78803 Advanced Imaging RP LOCLZJ TUM SPECT 1 AREA _ AIM Guidelines _

78804 Advanced Imaging RP LOCLZJ TUM WHBDY 2+D IMG _ AIM Guidelines _

78811 Advanced Imaging PET IMAGE LTD AREA _ AIM Guidelines _

78812 Advanced Imaging PET IMAGE SKULL-THIGH _ AIM Guidelines _

78813 Advanced Imaging PET IMAGE FULL BODY _ AIM Guidelines _

78814 Advanced Imaging PET IMAGE W/CT LMTD _ AIM Guidelines _

78815 Advanced Imaging PET IMAGE W/CT SKULL-THIGH _ AIM Guidelines _

78816 Advanced Imaging PET IMAGE W/CT FULL BODY _ AIM Guidelines _

78830 Advanced Imaging RP LOCLZJ TUM SPECT W/CT 1 _ AIM Guidelines _

78831 Advanced Imaging RP LOCLZJ TUM SPECT 2 AREAS _ AIM Guidelines _

78832 Advanced Imaging RP LOCLZJ TUM SPECT W/CT 2 _ AIM Guidelines _

78999 Advanced Imaging NUCLEAR DIAGNOSTIC EXAM _ AIM Guidelines _

79005 Radiation Oncology NUCLEAR RX ORAL ADMIN _ AIM Guidelines _

79101 Radiation Oncology NUCLEAR RX IV ADMIN _ AIM Guidelines _

79403 Radiation Oncology HEMATOPOIETIC NUCLEAR TX _ AIM Guidelines _

81162 Molecular and Genetic Lab BRCA1&2 GEN FULL SEQ DUP/DEL _ AIM Guidelines _

81163 Molecular and Genetic Lab BRCA1&2 GENE FULL SEQ ALYS _ AIM Guidelines _

81164 Molecular and Genetic Lab BRCA1&2 GEN FUL DUP/DEL ALYS _ AIM Guidelines _

81165 Molecular and Genetic Lab BRCA1 GENE FULL SEQ ALYS _ AIM Guidelines _

81166 Molecular and Genetic Lab BRCA1 GENE FULL DUP/DEL ALYS _ AIM Guidelines _

81167 Molecular and Genetic Lab BRCA2 GENE FULL DUP/DEL ALYS _ AIM Guidelines _

81173 Molecular and Genetic Lab AR GENE FULL GENE SEQUENCE _ AIM Guidelines _

81174 Molecular and Genetic Lab AR GENE KNOWN FAMIL VARIANT _ AIM Guidelines _

81185 Molecular and Genetic Lab CACNA1A GENE FULL GENE SEQ _ AIM Guidelines _

81186 Molecular and Genetic Lab CACNA1A GEN KNOWN FAMIL VRNT _ AIM Guidelines _

81189 Molecular and Genetic Lab CSTB GENE FULL GENE SEQUENCE _ AIM Guidelines _

81190 Molecular and Genetic Lab CSTB GENE KNOWN FAMIL VRNT _ AIM Guidelines _

81201 Molecular and Genetic Lab APC GENE FULL SEQUENCE _ AIM Guidelines _




81202 Molecular and Genetic Lab APC GENE KNOWN FAM VARIANTS _ AIM Guidelines _

81203 Molecular and Genetic Lab APC GENE DUP/DELET VARIANTS _ AIM Guidelines _

81212 Molecular and Genetic Lab BRCA1&2 185&5385&6174 VRNT _ AIM Guidelines _

81215 Molecular and Genetic Lab BRCA1 GENE KNOWN FAMIL VRNT _ AIM Guidelines _

81216 Molecular and Genetic Lab BRCA2 GENE FULL SEQ ALYS _ AIM Guidelines _

81217 Molecular and Genetic Lab BRCA2 GENE KNOWN FAMIL VRNT _ AIM Guidelines _

81221 Molecular and Genetic Lab CFTR GENE KNOWN FAM VARIANTS _ AIM Guidelines _

81222 Molecular and Genetic Lab CFTR GENE DUP/DELET VARIANTS _ AIM Guidelines _

81223 Molecular and Genetic Lab CFTR GENE FULL SEQUENCE _ AIM Guidelines _

81225 Molecular and Genetic Lab CYP2C19 GENE COM VARIANTS _ AIM Guidelines _

81226 Molecular and Genetic Lab CYP2D6 GENE COM VARIANTS _ AIM Guidelines _

81227 Molecular and Genetic Lab CYP2C9 GENE COM VARIANTS _ AIM Guidelines _

81228 Molecular and Genetic Lab CYTOGEN MICRARRAY COPY NMBR _ AIM Guidelines _

81229 Molecular and Genetic Lab CYTOGEN M ARRAY COPY NO&SNP _ AIM Guidelines _

81230 Molecular and Genetic Lab CYP3A4 GENE COMMON VARIANTS _ AIM Guidelines _

81231 Molecular and Genetic Lab CYP3A5 GENE COMMON VARIANTS _ AIM Guidelines _

81232 Molecular and Genetic Lab DPYD GENE COMMON VARIANTS _ AIM Guidelines _

81238 Molecular and Genetic Lab F9 FULL GENE SEQUENCE _ AIM Guidelines _

81248 Molecular and Genetic Lab G6PD KNOWN FAMILIAL VARIANT _ AIM Guidelines _

81249 Molecular and Genetic Lab G6PD FULL GENE SEQUENCE _ AIM Guidelines _

81252 Molecular and Genetic Lab GJB2 GENE FULL SEQUENCE _ AIM Guidelines _

81253 Molecular and Genetic Lab GJB2 GENE KNOWN FAM VARIANTS _ AIM Guidelines _

81257 Molecular and Genetic Lab HBA1/HBA2 GENE _ AIM Guidelines _

81258 Molecular and Genetic Lab HBA1/HBA2 GENE FAM VRNT _ AIM Guidelines _

81259 Molecular and Genetic Lab HBA1/HBA2 FULL GENE SEQUENCE _ AIM Guidelines _

81269 Molecular and Genetic Lab HBA1/HBA2 GENE DUP/DEL VRNTS _ AIM Guidelines _

81277 Molecular and Genetic Lab CYTOGENOMIC NEO MICRORA ALYS _ AIM Guidelines _

81283 Molecular and Genetic Lab IFNL3 GENE _ AIM Guidelines _

81286 Molecular and Genetic Lab FXN GENE FULL GENE SEQUENCE _ AIM Guidelines _

81289 Molecular and Genetic Lab FXN GENE KNOWN FAMIL VARIANT _ AIM Guidelines _

81291 Molecular and Genetic Lab MTHFR GENE _ AIM Guidelines _

81292 Molecular and Genetic Lab MLH1 GENE FULL SEQ _ AIM Guidelines _

81293 Molecular and Genetic Lab MLH1 GENE KNOWN VARIANTS _ AIM Guidelines _

81294 Molecular and Genetic Lab MLH1 GENE DUP/DELETE VARIANT _ AIM Guidelines _

81295 Molecular and Genetic Lab MSH2 GENE FULL SEQ _ AIM Guidelines _

81296 Molecular and Genetic Lab MSH2 GENE KNOWN VARIANTS _ AIM Guidelines _

81297 Molecular and Genetic Lab MSH2 GENE DUP/DELETE VARIANT _ AIM Guidelines _

81298 Molecular and Genetic Lab MSH6 GENE FULL SEQ _ AIM Guidelines _

81299 Molecular and Genetic Lab MSH6 GENE KNOWN VARIANTS _ AIM Guidelines _

81300 Molecular and Genetic Lab MSH6 GENE DUP/DELETE VARIANT _ AIM Guidelines _

81302 Molecular and Genetic Lab MECP2 GENE FULL SEQ _ AIM Guidelines _

81303 Molecular and Genetic Lab MECP2 GENE KNOWN VARIANT _ AIM Guidelines _

81304 Molecular and Genetic Lab MECP2 GENE DUP/DELET VARIANT _ AIM Guidelines _

81306 Molecular and Genetic Lab NUDT15 GENE COMMON VARIANTS _ AIM Guidelines _

81307 Molecular and Genetic Lab PALB2 GENE FULL GENE SEQ _ AIM Guidelines _

81308 Molecular and Genetic Lab PALB2 GENE KNOWN FAMIL VRNT _ AIM Guidelines _

81313 Molecular and Genetic Lab PCA3/KLK3 ANTIGEN _ AIM Guidelines _

81317 Molecular and Genetic Lab PMS2 GENE FULL SEQ ANALYSIS _ AIM Guidelines _

81318 Molecular and Genetic Lab PMS2 KNOWN FAMILIAL VARIANTS _ AIM Guidelines _

81319 Molecular and Genetic Lab PMS2 GENE DUP/DELET VARIANTS _ AIM Guidelines _

81321 Molecular and Genetic Lab PTEN GENE FULL SEQUENCE _ AIM Guidelines _

81322 Molecular and Genetic Lab PTEN GENE KNOWN FAM VARIANT _ AIM Guidelines _

81323 Molecular and Genetic Lab PTEN GENE DUP/DELET VARIANT _ AIM Guidelines _

81325 Molecular and Genetic Lab PMP22 GENE FULL SEQUENCE _ AIM Guidelines _

81326 Molecular and Genetic Lab PMP22 GENE KNOWN FAM VARIANT _ AIM Guidelines _

81327 Molecular and Genetic Lab SEPT9 GEN PRMTR MTHYLTN ALYS _ AIM Guidelines _

81328 Molecular and Genetic Lab SLCO1B1 GENE COM VARIANTS _ AIM Guidelines _

81335 Molecular and Genetic Lab TPMT GENE COM VARIANTS _ AIM Guidelines _

81336 Molecular and Genetic Lab SMN1 GENE FULL GENE SEQUENCE _ AIM Guidelines _

81337 Molecular and Genetic Lab SMN1 GEN NOWN FAMIL SEQ VRNT _ AIM Guidelines _

81346 Molecular and Genetic Lab TYMS GENE COM VARIANTS _ AIM Guidelines _

81350 Molecular and Genetic Lab UGT1A1 GENE COMMON VARIANTS _ AIM Guidelines _

81355 Molecular and Genetic Lab VKORC1 GENE _ AIM Guidelines _

81361 Molecular and Genetic Lab HBB GENE COM VARIANTS _ AIM Guidelines _

81362 Molecular and Genetic Lab HBB GENE KNOWN FAM VARIANT _ AIM Guidelines _

81363 Molecular and Genetic Lab HBB GENE DUP/DEL VARIANTS _ AIM Guidelines _

81364 Molecular and Genetic Lab HBB FULL GENE SEQUENCE _ AIM Guidelines _

81400 Molecular and Genetic Lab MOPATH PROCEDURE LEVEL 1 _ AIM Guidelines _









81410 Molecular and Genetic Lab AORTIC DYSFUNCTION/DILATION _ AIM Guidelines _

81411 Molecular and Genetic Lab AORTIC DYSFUNCTION/DILATION _ AIM Guidelines _

81412 Molecular and Genetic Lab ASHKENAZI JEWISH ASSOC DIS _ AIM Guidelines _

81413 Molecular and Genetic Lab CAR ION CHNNLPATH INC 10 GNS _ AIM Guidelines _

81414 Molecular and Genetic Lab CAR ION CHNNLPATH INC 2 GNS _ AIM Guidelines _




81415 Molecular and Genetic Lab EXOME SEQUENCE ANALYSIS _ AIM Guidelines _

81416 Molecular and Genetic Lab EXOME SEQUENCE ANALYSIS _ AIM Guidelines _

81417 Molecular and Genetic Lab EXOME RE-EVALUATION _ AIM Guidelines _

81422 Molecular and Genetic Lab FETAL CHRMOML MICRODELTJ _ AIM Guidelines _

81425 Molecular and Genetic Lab GENOME SEQUENCE ANALYSIS _ AIM Guidelines _

81426 Molecular and Genetic Lab GENOME SEQUENCE ANALYSIS _ AIM Guidelines _

81427 Molecular and Genetic Lab GENOME RE-EVALUATION _ AIM Guidelines _

81430 Molecular and Genetic Lab HEARING LOSS SEQUENCE ANALYS _ AIM Guidelines _

81431 Molecular and Genetic Lab HEARING LOSS DUP/DEL ANALYS _ AIM Guidelines _

81432 Molecular and Genetic Lab HRDTRY BRST CA-RLATD DSORDRS _ AIM Guidelines _

81433 Molecular and Genetic Lab HRDTRY BRST CA-RLATD DSORDRS _ AIM Guidelines _

81434 Molecular and Genetic Lab HEREDITARY RETINAL DISORDERS _ AIM Guidelines _

81435 Molecular and Genetic Lab HEREDITARY COLON CA DSORDRS _ AIM Guidelines _

81436 Molecular and Genetic Lab HEREDITARY COLON CA DSORDRS _ AIM Guidelines _

81437 Molecular and Genetic Lab HEREDTRY NURONDCRN TUM DSRDR _ AIM Guidelines _

81438 Molecular and Genetic Lab HEREDTRY NURONDCRN TUM DSRDR _ AIM Guidelines _

81439 Molecular and Genetic Lab HRDTRY CARDMYPY GENE PANEL _ AIM Guidelines _

81440 Molecular and Genetic Lab MITOCHONDRIAL GENE _ AIM Guidelines _

81442 Molecular and Genetic Lab NOONAN SPECTRUM DISORDERS _ AIM Guidelines _

81443 Molecular and Genetic Lab GENETIC TSTG SEVERE INH COND _ AIM Guidelines _

81445 Molecular and Genetic Lab TARGETED GENOMIC SEQ ANALYS _ AIM Guidelines _

81448 Molecular and Genetic Lab HRDTRY PERPH NEURPHY PANEL _ AIM Guidelines _



81460 Molecular and Genetic Lab WHOLE MITOCHONDRIAL GENOME _ AIM Guidelines _

81465 Molecular and Genetic Lab WHOLE MITOCHONDRIAL GENOME _ AIM Guidelines _

81470 Molecular and Genetic Lab X-LINKED INTELLECTUAL DBLT _ AIM Guidelines _

81471 Molecular and Genetic Lab X-LINKED INTELLECTUAL DBLT _ AIM Guidelines _

81479 Molecular and Genetic Lab UNLISTED MOLECULAR PATHOLOGY _ AIM Guidelines _

81490 Molecular and Genetic Lab AUTOIMMUNE RHEUMATOID ARTHR _ AIM Guidelines _

81493 Molecular and Genetic Lab COR ARTERY DISEASE MRNA _ AIM Guidelines _

81500 Molecular and Genetic Lab ONCO (OVAR) TWO PROTEINS _ AIM Guidelines _

81503 Molecular and Genetic Lab ONCO (OVAR) FIVE PROTEINS _ AIM Guidelines _

81504 Molecular and Genetic Lab ONCOLOGY TISSUE OF ORIGIN _ AIM Guidelines _

81518 Molecular and Genetic Lab ONC BRST MRNA 11 GENES _ AIM Guidelines _

81519 Molecular and Genetic Lab ONCOLOGY BREAST MRNA _ AIM Guidelines _

81520 Molecular and Genetic Lab ONC BREAST MRNA 58 GENES _ AIM Guidelines _



81525 Molecular and Genetic Lab ONCOLOGY COLON MRNA _ AIM Guidelines _

81535 Molecular and Genetic Lab ONCOLOGY GYNECOLOGIC _ AIM Guidelines _

81536 Molecular and Genetic Lab ONCOLOGY GYNECOLOGIC _ AIM Guidelines _

81538 Molecular and Genetic Lab ONCOLOGY LUNG _ AIM Guidelines _

81539 Molecular and Genetic Lab ONCOLOGY PROSTATE PROB SCORE _ AIM Guidelines _

81540 Molecular and Genetic Lab ONCOLOGY TUM UNKNOWN ORIGIN _ AIM Guidelines _

81541 Molecular and Genetic Lab ONC PROSTATE MRNA 46 GENES _ AIM Guidelines _

81542 Molecular and Genetic Lab ONC PROSTATE MRNA 22 CNT GEN _ AIM Guidelines _

81551 Molecular and Genetic Lab ONC PROSTATE 3 GENES _ AIM Guidelines _

81552 Molecular and Genetic Lab ONC UVEAL MLNMA MRNA 15 GENE _ AIM Guidelines _

81595 Molecular and Genetic Lab CARDIOLOGY HRT TRNSPL MRNA _ AIM Guidelines _

81596 Molecular and Genetic Lab NFCT DS CHRNC HCV 6 ASSAYS _ AIM Guidelines _

81599 Molecular and Genetic Lab UNLISTED MAAA _ AIM Guidelines _

84999 Molecular and Genetic Lab CLINICAL CHEMISTRY TEST _ AIM Guidelines _

95807 Select Outpatient Services SLEEP STUDY ATTENDED MED204.005 Diagnosis and Medical Management of

Obstructive Sleep Apnea Syndrome_

95808 Select Outpatient Services POLYSOM ANY AGE 1-3> PARAMMED201.049

MED204.005

Diagnosis and Medical Management of

Obstructive Sleep Apnea Syndrome

Polysomnography for Non-Respiratory

Sleep Disorders

_

95810 Select Outpatient Services POLYSOM 6/> YRS 4/> PARAMMED201.049

MED204.005




Sleep Disorders

_

95811 Select Outpatient Services POLYSOM 6/>YRS CPAP 4/> PARMMED201.049

MED204.005




Sleep Disorders

_

95980 Select Outpatient Services IO ANAL GAST N-STIM INIT SUR709.031 Gastric Electrical Stimulation (GES) _

99183 Select Outpatient Services HYPERBARIC OXYGEN THERAPY THE801.003 Hyperbaric Oxygen (HBO2) Therapy _

0001U Molecular and Genetic Lab RBC DNA HEA 35 AG 11 BLD GRP _ AIM Guidelines _

0002M Molecular and Genetic Lab Liver dis 10 assays w/ash _ AIM Guidelines _

0003M Molecular and Genetic Lab Liver dis 10 assays w/nash _ AIM Guidelines _

0004M Molecular and Genetic Lab Scoliosis dna alys _ AIM Guidelines _

0005U Molecular and Genetic Lab ONCO PRST8 3 GENE UR ALG _ AIM Guidelines _

0006M Molecular and Genetic Lab Onc hep gene risk classifier _ AIM Guidelines _

0007M Molecular and Genetic Lab Onc gastro 51 gene nomogram _ AIM Guidelines _

0011M Molecular and Genetic Lab ONC PRST8 CA MRNA 12 GEN ALG _ AIM Guidelines _




0012M Molecular and Genetic Lab ONC MRNA 5 GEN RSK URTHL CA _ AIM Guidelines _

0012U Molecular and Genetic Lab GERMLN DO GENE REARGMT DETCJ _ AIM Guidelines _

0013M Molecular and Genetic Lab ONC MRNA 5 GEN RECR URTHL CA _ AIM Guidelines _

0013U Molecular and Genetic Lab ONC SLD ORG NEO GENE REARGMT _ AIM Guidelines _

0014U Molecular and Genetic Lab HEM HMTLMF NEO GENE REARGMT _ AIM Guidelines _

0018U Molecular and Genetic Lab ONC THYR 10 MICRORNA SEQ ALG _ AIM Guidelines _

0019U Molecular and Genetic Lab ONC RNA TISS PREDICT ALG _ AIM Guidelines _

0022U Molecular and Genetic Lab TRGT GEN SEQ DNA&RNA 23 GENE _ AIM Guidelines _

0026U Molecular and Genetic Lab ONC THYR DNA&MRNA 112 GENES _ AIM Guidelines _

0029U Molecular and Genetic Lab RX METAB ADVRS TRGT SEQ ALYS _ AIM Guidelines _

0030U Molecular and Genetic Lab RX METAB WARF TRGT SEQ ALYS _ AIM Guidelines _

0031U Molecular and Genetic Lab CYP1A2 GENE _ AIM Guidelines _

0032U Molecular and Genetic Lab COMT GENE _ AIM Guidelines _

0033U Molecular and Genetic Lab HTR2A HTR2C GENES _ AIM Guidelines _

0034U Molecular and Genetic Lab TPMT NUDT15 GENES _ AIM Guidelines _

0036U Molecular and Genetic Lab XOME TUM & NML SPEC SEQ ALYS _ AIM Guidelines _

0037U Molecular and Genetic Lab TRGT GEN SEQ DNA 324 GENES _ AIM Guidelines _

0042T Advanced Imaging CT PERFUSION W/CONTRAST CBF _ AIM Guidelines _

0045U Molecular and Genetic Lab ONC BRST DUX CARC IS 12 GENE _ AIM Guidelines _

0047U Molecular and Genetic Lab ONC PRST8 MRNA 17 GENE ALG _ AIM Guidelines _

0048U Molecular and Genetic Lab ONC SLD ORG NEO DNA 468 GENE _ AIM Guidelines _

0050U Molecular and Genetic Lab TRGT GEN SEQ DNA 194 GENES _ AIM Guidelines _

0053U Molecular and Genetic Lab ONC PRST8 CA FISH ALYS 4 GEN _ AIM Guidelines _

0055U Molecular and Genetic Lab CARD HRT TRNSPL 96 DNA SEQ _ AIM Guidelines _

0056U Molecular and Genetic Lab HEM AML DNA GENE REARGMT _ AIM Guidelines _

0060U Molecular and Genetic Lab TWN ZYG GEN SEQ ALYS CHRMS2 _ AIM Guidelines _

0067U Molecular and Genetic Lab ONC BRST IMHCHEM PRFL 4 BMRK _ AIM Guidelines _

0069U Molecular and Genetic Lab ONC CLRCT MICRORNA MIR-31-3P _ AIM Guidelines _

0070U Molecular and Genetic Lab CYP2D6 GEN COM&SLCT RAR VRNT _ AIM Guidelines _

0071U Molecular and Genetic Lab CYP2D6 FULL GENE SEQUENCE _ AIM Guidelines _

0072U Molecular and Genetic Lab CYP2D6 GEN CYP2D6-2D7 HYBRID _ AIM Guidelines _

0073U Molecular and Genetic Lab CYP2D6 GEN CYP2D7-2D6 HYBRID _ AIM Guidelines _

0074U Molecular and Genetic Lab CYP2D6 NONDUPLICATED GENE _ AIM Guidelines _

0075U Molecular and Genetic Lab CYP2D6 5' GENE DUP/MLT _ AIM Guidelines _

0076U Molecular and Genetic Lab CYP2D6 3' GENE DUP/MLT _ AIM Guidelines _

0078U Molecular and Genetic Lab PAIN MGT OPI USE GNOTYP PNL _ AIM Guidelines _

0079U Molecular and Genetic Lab CMPRTV DNA ALYS MLT SNPS _ AIM Guidelines _

0084U Molecular and Genetic Lab RBC DNA GNOTYP 10 BLD GROUPS _ AIM Guidelines _

0087U Molecular and Genetic Lab CRD HRT TRNSPL MRNA 1283 GEN _ AIM Guidelines _

0088U Molecular and Genetic Lab TRNSPLJ KDN ALGRFT REJ 1494 _ AIM Guidelines _

0089U Molecular and Genetic Lab ONC MLNMA PRAME & LINC00518 _ AIM Guidelines _

0090U Molecular and Genetic Lab ONC CUTAN MLNMA MRNA 23 GENE _ AIM Guidelines _

0094U Molecular and Genetic Lab GENOME RAPID SEQUENCE ALYS _ AIM Guidelines _

0095T Joint, Spine Surgery RMVL ARTIFIC DISC ADDL CRVCL _ AIM Guidelines _

0098T Joint, Spine Surgery REV ARTIFIC DISC ADDL _ AIM Guidelines _

0101U Molecular and Genetic Lab HERED COLON CA DO 15 GENES _ AIM Guidelines _

0102U Molecular and Genetic Lab HERED BRST CA RLTD DO 17 GEN _ AIM Guidelines _

0103U Molecular and Genetic Lab HERED OVA CA PNL 24 GENES _ AIM Guidelines _

0111U Molecular and Genetic Lab ONC COLON CA KRAS&NRAS ALYS _ AIM Guidelines _

0113U Molecular and Genetic Lab ONC PRST8 PCA3&TMPRSS2-ERG _ AIM Guidelines _

0114U Molecular and Genetic Lab GI BARRETTS ESOPH VIM&CCNA1 _ AIM Guidelines _

0118U Molecular and Genetic Lab TRNSPLJ DON-DRV CLL-FR DNA _ AIM Guidelines _

0120U Molecular and Genetic Lab ONC B CLL LYMPHM MRNA 58 GEN _ AIM Guidelines _

0129U Molecular and Genetic Lab HERED BRST CA RLTD DO PANEL _ AIM Guidelines _

0130U Molecular and Genetic Lab HERED COLON CA DO MRNA PNL _ AIM Guidelines _

0131U Molecular and Genetic Lab HERED BRST CA RLTD DO PNL 13 _ AIM Guidelines _

0132U Molecular and Genetic Lab HERED OVA CA RLTD DO PNL 17 _ AIM Guidelines _

0133U Molecular and Genetic Lab HERED PRST8 CA RLTD DO 11 _ AIM Guidelines _

0134U Molecular and Genetic Lab HERED PAN CA MRNA PNL 18 GEN _ AIM Guidelines _

0135U Molecular and Genetic Lab HERED GYN CA MRNA PNL 12 GEN _ AIM Guidelines _

0136U Molecular and Genetic Lab ATM MRNA SEQ ALYS _ AIM Guidelines _

0137U Molecular and Genetic Lab PALB2 MRNA SEQ ALYS _ AIM Guidelines _

0138U Molecular and Genetic Lab BRCA1 BRCA2 MRNA SEQ ALYS _ AIM Guidelines _

0153U Molecular and Genetic Lab ONC BREAST MRNA 101 GENES _ AIM Guidelines _

0156U Molecular and Genetic Lab COPY NUMBER SEQUENCE ALYS _ AIM Guidelines _

0157U Molecular and Genetic Lab APC MRNA SEQ ALYS _ AIM Guidelines _

0158U Molecular and Genetic Lab MLH1 MRNA SEQ ALYS _ AIM Guidelines _

0159U Molecular and Genetic Lab MSH2 MRNA SEQ ALYS _ AIM Guidelines _

0160U Molecular and Genetic Lab MSH6 MRNA SEQ ALYS _ AIM Guidelines _

0161U Molecular and Genetic Lab PMS2 MRNA SEQ ALYS _ AIM Guidelines _

0162U Molecular and Genetic Lab HERED COLON CA TRGT MRNA PNL _ AIM Guidelines _

0163T Joint, Spine Surgery LUMB ARTIF DISKECTOMY ADDL _ AIM Guidelines _

0164T Joint, Spine Surgery REMOVE LUMB ARTIF DISC ADDL _ AIM Guidelines _

0165T Joint, Spine Surgery REVISE LUMB ARTIF DISC ADDL _ AIM Guidelines _

0169U Molecular and Genetic Lab NUDT15&TPMT GENE COM VRNT _ AIM Guidelines _

0170U Molecular and Genetic Lab NEURO ASD RNA NEXT GEN SEQ _ AIM Guidelines _

0171U Molecular and Genetic Lab TRGT GEN SEQ ALYS PNL DNA 23 _ AIM Guidelines _

0213T Pain Management NJX PARAVERT W/US CER/THOR _ AIM Guidelines _



0216T Pain Management NJX PARAVERT W/US LUMB/SAC _ AIM Guidelines _






0274T Pain Management PERQ LAMOT/LAM CRV/THRC _ AIM Guidelines _

0275T Pain Management PERQ LAMOT/LAM LUMBAR _ AIM Guidelines _

0312T Select Outpatient Services LAPS IMPLTJ NSTIM VAGUS SUR701.039Vagus Nerve Blocking Therapy for

Treatment of Obesity_

0313T Select Outpatient Services LAPS RMVL NSTIM ARRAY VAGUS SUR701.039Vagus Nerve Blocking Therapy for


0314T Select Outpatient Services LAPS RMVL VGL ARRY&PLS GEN SUR701.039Vagus Nerve Blocking Therapy for


0315T Select Outpatient Services RMVL VAGUS NERVE PLS GEN SUR701.039Vagus Nerve Blocking Therapy for


0316T Select Outpatient Services REPLC VAGUS NERVE PLS GEN SUR701.039Vagus Nerve Blocking Therapy for


0317T Select Outpatient Services ELEC ALYS VAGUS NRV PLS GEN SUR701.039Vagus Nerve Blocking Therapy for


0394T Radiation Oncology HDR ELCTRNC SKN SURF BRCHYTX _ AIM Guidelines _

0395T Radiation Oncology HDR ELCTR NTRST/NTRCV BRCHTX _ AIM Guidelines _

A0430 Select Outpatient ServicesAmbulance service conventional air services transport one way

(fixed wing)ADM1001.005

Ambulance and Medical Transport

Services_

A0435 Select Outpatient Services Fixed wing air mileage per statute mile ADM1001.005Ambulance and Medical Transport

Services_

A4290 Select Outpatient Services Sacral nerve stimulation test lead each SUR710.018Sacral Nerve


A4575 Select Outpatient Services Topical hyperbaric oxygen chamber disposable THE801.003 Hyperbaric Oxygen (HBO2) Therapy _

A9513 Radiation Oncology Lutetium lu 177 dotatate therapeutic 1 millicurie _ AIM Guidelines _

A9543 Radiation OncologyYTTRIUM Y-90 IBRITUMOMAB TIUXETAN THERAPEUTIC PER

TREATMENT DOSE UP TO 40 MILLICURIES_ AIM Guidelines _

A9590 Radiation Oncology Iodine i-131 iobenguane 1 millicurie _ AIM Guidelines _

A9606 Radiation Oncology Radium ra-223 dichloride therapeutic per microcurie _ AIM Guidelines _

C8900 Advanced Imaging Magnetic resonance angiography with contrast abdomen _ AIM Guidelines _

C8901 Advanced Imaging Magnetic resonance angiography without contrast abdomen _ AIM Guidelines _

C8902 Advanced ImagingMagnetic resonance angiography without contrast followed by with

contrast abdomen_ AIM Guidelines _

C8903 Advanced Imaging Magnetic resonance imaging with contrast breast; unilateral _ AIM Guidelines _

C8905 Advanced ImagingMagnetic resonance imaging without contrast followed by with

contrast breast; unilateral_ AIM Guidelines _

C8906 Advanced Imaging Magnetic resonance imaging with contrast breast; bilateral _ AIM Guidelines _

C8908 Advanced ImagingMagnetic resonance imaging without contrast followed by with

contrast breast; bilateral_ AIM Guidelines _

C8909 Advanced ImagingMagnetic resonance angiography with contrast chest (excluding

myocardium)_ AIM Guidelines _

C8910 Advanced ImagingMagnetic resonance angiography without contrast chest (excluding

myocardium)_ AIM Guidelines _


contrast chest (excluding myocardium)_ AIM Guidelines _

C8912 Advanced Imaging Magnetic resonance angiography with contrast lower extremity _ AIM Guidelines _

C8913 Advanced Imaging Magnetic resonance angiography without contrast lower extremity _ AIM Guidelines _


contrast lower extremity_ AIM Guidelines _

C8918 Advanced Imaging Magnetic resonance angiography with contrast pelvis _ AIM Guidelines _

C8919 Advanced Imaging Magnetic resonance angiography without contrast pelvis _ AIM Guidelines _


contrast pelvis_ AIM Guidelines _

C8931 Advanced ImagingMagnetic resonance angiography with contrast spinal canal and

contents_ AIM Guidelines _

C8932 Advanced ImagingMagnetic resonance angiography without contrast spinal canal and

contents_ AIM Guidelines _


contrast spinal canal and contents_ AIM Guidelines _

C8934 Advanced Imaging Magnetic resonance angiography with contrast upper extremity _ AIM Guidelines _

C8935 Advanced Imaging Magnetic resonance angiography without contrast upper extremity _ AIM Guidelines _


contrast upper extremity_ AIM Guidelines _

C9757 Joint, Spine Surgery

Laminotomy (hemilaminectomy) with decompression of nerve

root(s) including partial facetectomy foraminotomy and excision of

herniated intervertebral disc and repair of annular defect with

implantation of bone anchored annular closure device including

annular defect measurement alignment and sizing assessment and

image guidance; 1 interspace lumbar

_ AIM Guidelines _

E0745 Select Outpatient Services Neuromuscular stimulator electronic shock unit SUR710.018Sacral Nerve


E0748 Joint, Spine Surgery Osteogenesis stimulator electrical non-invasive spinal applications _ AIM Guidelines _

E0749 Joint, Spine Surgery Osteogenesis stimulator electrical surgically implanted _ AIM Guidelines _

E0760 Select Outpatient Services Osteogenesis stimulator low intensity ultrasound non-invasive MED201.033Functional Neuromuscular Electrical

Stimulation (FNMES)_

E0765 Select Outpatient ServicesFda approved nerve stimulator with replaceable batteries for

treatment of nausea and vomitingSUR709.031 Gastric Electrical Stimulation (GES) _




E0770 Select Outpatient Services

FUNCTIONAL ELECTRICAL STIMULATOR TRANSCUTANEOUS

STIMULATION OF NERVE AND/OR MUSCLE GROUPS ANY TYPE

COMPLETE SYSTEM NOT OTHERWISE SPECIFIED

MED201.033Functional Neuromuscular Electrical

Stimulation (FNMES)_

G0219 Advanced Imaging Pet imaging whole body; melanoma for non-covered indications _ AIM Guidelines _

G0235 Advanced Imaging Pet imaging any site not otherwise specified _ AIM Guidelines _

G0252 Advanced Imaging

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)

_ AIM Guidelines _

G0277 Select Outpatient ServicesHyperbaric oxygen under pressure full body chamber per 30 minute

intervalTHE801.003 Hyperbaric Oxygen (HBO2) Therapy _

G0297 Advanced Imaging Low dose ct scan (ldct) for lung cancer screening _ AIM Guidelines _

G0339 Radiation Oncology

Image-guided robotic linear accelerator-based stereotactic

radiosurgery complete course of therapy in one session or first

session of fractionated treatment

_ AIM Guidelines _


Image-guided robotic linear accelerator-based stereotactic

radiosurgery delivery including collimator changes and custom

plugging fractionated treatment all lesions per session second

through fifth sessions maximum five sessions per course of treatment

_ AIM Guidelines _

G6001 Radiation Oncology Ultrasonic guidance for placement of radiation therapy fields _ AIM Guidelines _

G6002 Radiation OncologyStereoscopic x-ray guidance for localization of target volume for the

delivery of radiation therapy_ AIM Guidelines _

G6003 Radiation OncologyRadiation treatment delivery single treatment area single port or

parallel opposed ports simple blocks or no blocks: up to 5mev_ AIM Guidelines _


parallel opposed ports simple blocks or no blocks: 6-10mev_ AIM Guidelines _


parallel opposed ports simple blocks or no blocks: 11-19mev_ AIM Guidelines _


parallel opposed ports simple blocks or no blocks: 20mev or greater_ AIM Guidelines _

G6007 Radiation OncologyRadiation treatment delivery 2 separate treatment areas 3 or more

ports on a single treatment area use of multiple blocks: up to 5mev_ AIM Guidelines _


ports on a single treatment area use of multiple blocks: 6-10mev_ AIM Guidelines _


ports on a single treatment area use of multiple blocks: 11-19mev_ AIM Guidelines _


Radiation treatment delivery 2 separate treatment areas 3 or more

ports on a single treatment area use of multiple blocks: 20 mev or

greater

_ AIM Guidelines _


Radiation treatment delivery 3 or more separate treatment areas

custom blocking tangential ports wedges rotational beam

compensators electron beam; up to 5mev

_ AIM Guidelines _




compensators electron beam; 6-10mev

_ AIM Guidelines _




compensators electron beam; 11-19mev

_ AIM Guidelines _




compensators electron beam; 20mev or greater

_ AIM Guidelines _


Intensity modulated treatment delivery single or multiple fields/arcs

via narrow spatially and temporally modulated beams binary

dynamic mlc per treatment session

_ AIM Guidelines _


Compensator-based beam modulation treatment delivery of inverse

planned treatment using 3 or more high resolution (milled or cast)

compensator convergent beam modulated fields per treatment

session

_ AIM Guidelines _


Intra-fraction localization and tracking of target or patient motion

during delivery of radiation therapy (eg 3d positional tracking gating

3d surface tracking) each fraction of treatment

_ AIM Guidelines _

G9143 Molecular and Genetic LabWarfarin responsiveness testing by genetic technique using any

method any number of specimen(s)_ AIM Guidelines _

L8600 Select Outpatient Services Implantable breast prosthesis silicone or equal SUR716.010 Mastopexy _

L8614 Select Outpatient ServicesCOCHLEAR DEVICE INCLUDES ALL INTERNAL AND EXTERNAL

COMPONENTSSUR714.004 Cochlear Implant _

L8615 Select Outpatient ServicesHEADSET/HEADPIECE FOR USE WI

Documents

2021 Commercial Outpatient Benefit Preauthorization Fully ... · CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including