Medicaid Prior Authorization (PA) Code Matrix · H0015: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week

Molina Healthcare of South Carolina, Inc.

Medicaid Prior Authorization Matrix

Q4, Eff October 1, 2020 1

Effective October 1, 2020 Medicaid Prior Authorization (PA) Code Matrix

FOR ANY PRIOR AUTHORIZATION CHANGES DUE TO REGULATORY GUIDANCE RELATED TO COVID 19 –

PLEASE SEE PROVIDER NOTIFICATIONS AND MOST CURRENT INFORMATION ON THE PROVIDER PORTAL. General Provisions:

>S ome service s listed may n ot b e covered by CM S or you r local Stat e Regulatory Agency.

>Th e absenc e of a cod e from thi s lis t should n ot b e used to determin e whethe r a servic e i s covered or n ot by you r regulatory

agency.

>Refe r to you r regulatory agency f or benefi t coverag e and non-covered codes.

>Pri or Authorization i s n ot a guarante e of paymen t f or services.

>Paymen t i s mad e in accordanc e with a determination of th e member’ s eligibility on th e date(s) of service,

benefi t limitation s or exclusion s and, othe r applicabl e standard s during th e claim review, including th e ter ms of any

applicabl e provide r agreement.

Non-PAR Offices/Providers/Facilities: >All Non-Pa r Provider s requir e authorization regardles s of service s or codes

>An y exception s included in thi s Pri or Authorization Cod e Matrix documen t apply to PAR Provider s only.

>All Non-Pa r Provider s requir e authorization regardles s of service s or codes

>Pri or Authorization required f or Non-Pa r Offic e Visits; Surgical Procedures, Labs, Diagnosti c Studies, In-patien t stays, excep t for:

Emergency Departmen t Services,

Professional fee s associated with an Emergency Departmen t visi t and approved Ambulatory Surgery Cente r (ASC) or in-patien t stay;

Local Health Departmen t (LHD) services; Othe r service s based on Stat e requirements/exceptions

Inpatient Services: >All Elective In-Patient admits/services require Prior Authorization, including:�

Acute Hospital, Skilled Nursing Facilities (SNF), Rehabilitation, and Long Term Acute Care (LTAC) Facilities with the exception of hospice.�>Hospice does NOT require prior authorization but rather simply notification of services.�>No Prior Authorization Required for Emergency Services for PAR or NON PAR Providers.�

>All urgent/emergent inpatient admissions require that authorization be obtained and Molina notified of the admission within 1 business day.�Out-Patient Services:

>These codes are for Out-Patient services only.�>No Pri or Authorization required f or offic e visit s a t Participating (PAR) Networ k Providers. PAR Office-Based Procedure s do n ot requir e authorization,�

unles s specifically included in anothe r servic e category tha t require s authorization even when performed in a participating provider' s office. �>Long Term Service s and Suppor t (LTSS): Codes/service s regardles s of code(s) i s NOT a covered benefi t f or Molin a Healthcar e of South Carolina.�

>Dental Procedures: Notification i s required f or any dental procedur e tha t i s performed in an Non-Pa r Outpatien t or Ambulatory Surgical Cente r {PO S 22, 24}.�>Dialysis: Molin a Healthcar e of South Carolin a require s notification of dialysis.�

DentaQues t provide s revie w of all dental procedure s and evidenc e of thi s approval (vi a DentaQues t lette r or fax) mus t b e submitted with such requests. �Molin a Healthcar e of South Carolin a require s notification of thes e planned services.�

>No pri or authorization i s required f or circumcision s up to 365 day s pos t birth.�>Incontinenc e Supplies: Doe s NOT requir e Pri or Authorization up to allowabl e amounts. F or member s 4 year s of ag e and older:�

Physician mus t certify, in writing, th e membe r ha s an inability to control bowel or bladde r function. �Physician Certification of Incontinenc e Form mus t b e completed b y th e Primar y Car e Physician f or a 3, 6, 9 or 12 month timefra me (a s chosen by th e physician). �

Physician Certification of Incontinenc e For ms MUST b e kep t on fil e by th e Incontinenc e Supply Provide r and ar e subjec t to validation and auditing.�>Healthcar e Administered Drugs: Newl y FDA approved medication s such a s “buy-and-bill” drug s ar e considered non-formulary and subjec t to non-formulary policies�

an d othe r non-formular y utilizati on criteri a until a coverag e decisi on i s rendere d b y th e Molin a Pharmac y an d Therapeutic s Committee.� “Buy-and-bill” drug s ar e pharmaceutical s whic h a provide r purchase s and administers, an d f or whic h th e provide r submit s a claim to Molin a Healthcar e f or reimbursement. �

Man y self-administere d an d office-administere d injectabl e product s requir e Pri or Authorizati on (PA). �I n s ome case s the y will b e mad e availabl e throug h Molin a Healthcare’ s vendor, Caremar k Specialt y Pharmacy. Molina’ s pharmacy vend or will coordinat e with MHI and ship th e prescription directly to you r offic e or th e member’ s home.�

All package s ar e individuall y marke d f or eac h member, an d refrigerate d drug s ar e shippe d i n insulate d package s with frozen gel packs. �Th e servic e also offer s th e additional convenienc e of enclosin g neede d ancillar y supplie s (needles, syringe s and alcohol swabs) with each prescription a t no charge. �

Pleas e contac t you r Provide r Relation s Representativ e wit h an y furthe r question s abou t th e program.�



Q4, Eff October 1, 2020

This document is NOT be utilized to make benefit coverage determinations.

Matrix Service Category Code Definition SC P A

Required SC State Exception Notes

Behavioral/Menta l Health , Alcohol-Chemica l Dependency

80305 Dru g test(s) , presumptive , an y numbe r o f dru g classes , an y number o f device s o r procedures ; capable o f bein g rea d b y dire ct optical observatio n onl y (eg , utilizin g immunoassa y [eg , dipstick s, cup s, card s, o r cartridges]) , includes sample validatio n whe n performed ,

Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n i s require d afte r 24 unit s have bee n use d (an y combination)


80306 Dru g test(s) , presumptive , an y numbe r o f dru g classes , an y number o f devices o r procedures ; rea d b y instrumen t assiste d dire ct optical observatio n (eg , utilizin g immunoassa y [eg , dipstick s, cup s, cards , o r cartridges]) , includes sample validatio n whe n performed , per



80307 Dru g test(s) , presumptive , an y numbe r o f dru g classes , an y number o f devices o r procedures ; b y instrumen t chemistr y analyzers (eg , utilizin g immunoassa y [eg , EIA , ELISA , EMIT , FPIA , IA , KIMS , RIA]) , chromatograph y (eg , GC , HPLC) , an d mas s spectrometr y eithe r with



80320 DRU G TES T DE F DRU G TESTIN G PROCEDURES Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n i s require d afte r 2 4 unit s have bee n use d (an y combination)


80324 DRU G TES T DE F DRU G TESTIN G PROCEDURES Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n i s require d afte r 2 4 unit s have bee n use d (an y combination)


80346 DRU G TES T DE F DRU G TESTIN G PROCEDURES Y EFFECTIV E 8/1/2020 : Prio r Authorizatio n i s require d afte r 2 4 unit s have bee n use d (an y combination)


80348 DRU G TES T DE F DRU G TESTIN G PROCEDURES Y EFFECTIV E 8/1/2020 : Prio r Authorizatio n i s require d afte r 2 4 unit s have bee n use d (an y combination)


80353 DRU G TES T DE F DRU G TESTIN G PROCEDURES Y EFFECTIV E 8/1/2020 : Prio r Authorizatio n i s require d afte r 2 4 unit s hav e bee n use d (an y combination)



















2



Behavioral/Menta l Health , Alcohol-Chemica l Dependency�

80373 DRU G TES T DE F DRU G TESTIN G PROCEDURES Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n i s require d afte r 24 unit s have bee n use d (an y combination)


90832 Psychotherapy , 30 minute s wit h patient Y Y Authorizatio n require d afte r 2 4 visit s annuall y (Yea r considere d 7/ 1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y

(ECT) , Applie d Behavio r Analysi s (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90833 Psychotherapy , 3 0 minute s wit h patien t whe n performe d wit h an evaluatio n an d managemen t service (Lis t separatel y i n additio n to the code fo r primar y procedure)

Y Y Authorizatio n require d afte r 2 4 visit s annuall y (Yea r considere d 7/ 1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y

(ECT) , Applie d Behavio r Analysi s (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90834 Psychotherapy , 4 5 minute s wit h patient Y Y Authorizatio n require d afte r 2 4 visit s annuall y (Yea r considere d 7/ 1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y

(ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD). Behavioral/Menta l Health , Alcohol-

Chemica l Dependency�90836 Psychotherapy , 45 minute s wit h patien t whe n performe d wit h an

evaluatio n an d managemen t service (Lis t separatel y i n additio n to the code fo r primar y procedure)

Y Y Authorizatio n require d afte r 24 visit s annuall y (Yea r considere d 7/1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y

(ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90837 Psychotherapy , 60 minute s wit h patient Y Y Authorizatio n require d afte r 2 4 visit s annuall y (Yea r considere d 7/ 1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y


Chemica l Dependency�90838 Psychotherapy , 60 minute s wit h patien t whe n performe d wit h an

evaluatio n an d managemen t service (Lis t separatel y i n additio n to the code fo r primar y procedure)

Y Y Authorizatio n require d afte r 24 visit s annuall y (Yea r considere d 7/1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y


Chemica l Dependency�90846 Famil y psychotherap y (withou t the patien t present) , 50 minutes Y Y Authorizatio n require d afte r 24 visits annuall y (Yea r considere d 7/1 - 6/30)

Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90847 Famil y psychotherap y (conjoin t psychotherapy ) (wit h patien t present) , 50 minutes

Y Y Authorizatio n require d afte r 24 visits annuall y (Yea r considere d 7/1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y



90849 Multiple-famil y grou p psychotherapy Y Y Authorizatio n require d afte r 24 visits annuall y (Yea r considere d 7/1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y


Chemica l Dependency�90853 Grou p psychotherap y (othe r tha n o f a multiple-famil y group) Y Y Authorizatio n require d afte r 24 visits annuall y (Yea r considere d 7/1 - 6/30)

Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90867 REPE T TM S T X INITIA L W MA P MOTR THRESHLD DE L AND MN G Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90868 THERA P REPETITIVE TM S T X SUBSEQ DELIVERY AND MNG Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90869 REPE T TM S T X SUBSEQ MOTR THRESHLD W DELI V AND MNG Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


90870 ELECTROCONVULSIVE THERAPY (ECT ) Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


97153 ADAPTIVE BEHAVIOR T X BY PROTOCO L TECH E A 15 MIN

Y


97154 GROU P ADAPTIVE BH V T X BY PROTOCO L TECH E A 15 MIN Y


97155 ADAP T BH V T X PRTC L MODIFICA J PHY S QH P E A 15 MIN Y


97156 FAMILY ADAP T BH V T X GD N PHY S QH P E A 15 MIN Y


97157 MULTIPLE FA M GROU P BH V T X GD N PHY S QH P E A 15 MIN Y


97158 G RP ADAP T BH V PRTC L MODIFCA J PHY S QH P E A 15 MIN Y


0373T ADAP T BH V T X PRTC L MODIFICA J E A 15 MI N TECH TIME Y


G0480 DRU G TES T DE F 1-7 CLASSES Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n is require d afte r 12 units have bee n use d (an y combination)










G0481 DRU G TES T DE F 1-7 CLASSES Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n is require d afte r 12 units have bee n use d (an y combination)


G0482 DRU G TES T DE F 1-7 CLASSES Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n i s require d afte r 1 2 unit s have bee n use d (an y combination)


G0483 DRU G TES T DE F 1- 7 CLASSES Y EFFECTIV E 8/1/2020 : Prio r Authorizatio n i s require d afte r 1 2 unit s have bee n use d (an y combination)


G0659 Dru g test(s) , definitive , utilizin g dru g identificatio n method s able to identif y individua l drug s an d distinguis h betwee n structural isomer s (bu t no t necessaril y stereoisomers) , fo r ea ch drug , dru g metabolite o r dru g clas s pe r specimen ; qualitative o r quantitative , al l sources , includes specime n validit y testing , pe r day , an y number

Y EFFECTIVE 8/1/2020 : Prio r Authorizatio n i s require d afte r 1 2 unit s have bee n use d (an y combination)


H0004 Behaviora l healt h counselin g an d therapy , pe r 15 minutes Y Y Authorizatio n require d afte r 24 visit s annuall y (Yea r considere d 7/1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y



H0005 Alcoho l and/o r dru g services ; grou p counselin g b y a clinician Y Y Authorizatio n require d afte r 24 visits annuall y (Yea r considere d 7/1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y


H0010 Alcoho l and/o r dru g services ; subacute detoxificatio n (residential addictio n program inpatient)

Y Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


H0011 Alcoho l and/o r dru g services ; acute detoxificatio n (residential addictio n program inpatient)



H0012 ALCOHO L AND DRU G SRVC ; SUB-ACUTE DTO X RE S PRO G O P Y Authorizatio n require d afte r 24 visits annuall y (Yea r considere d 7/1 - 6/30) Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y


H0015 Alcoho l and/o r dru g services ; intensive outpatien t (treatmen t program tha t operates a t lea st 3 hours/da y an d a t lea st 3

Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


H0018 Behaviora l health ; short-term residentia l (non-hospita l residential treatmen t program) , withou t room an d board , pe r diem



H0019

Behaviora l health ; long-term residentia l (non-medical , non-acute care i n a residentia l treatmen t program where sta y i s typicall y



H0046 THERAPEUTI C BEHAVIORA L SERVICE S PER DIEM Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


H2014 MENTA L HEALTH PARTIA L HOS P T X UNDER 24 HOU RS



H2017 PSYCHIATRI C HEALTH FACILITY SERVICE PER DIEM Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


H2030 Menta l healt h clubhouse services , pe r 15 minutes Y Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


H2035 Alcohol and/or other drug treatment program, per hour Y Y Prior Authorization required for DAODAS Providers only Inpatient, Residential Treatment, Partial Hospitalization, Electroconvulsive Therapy


H2036 Programs wit h 16 o r fewe r bed s: Alcoho l and/o r dru g treatmen t program , pe r diem , pe r patient



H2037 Developmenta l dela y preventio n activities , dependen t chil d o f client , pe r 15 minutes



S9480 INTENSIVE O P PSYCHIATRY Y


S9482 Famil y stabilizatio n service s, pe r 15 minutes Y Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).


T1027 FAMILY TRAI N AND COUNSE L CHILD DEVELOPMEN T 15 MIN S Y Inpatient , Residentia l Treatment , Partia l Hospitalization , Electroconvulsive Therap y (ECT) , Applie d Behavio r Analysis (ABA ) fo r t x o f Autism Spectrum Disorde r (ASD).

Cosmeti c, Plasti c & Reconstructive Procedures [I n an y Setting]

11920 TATTOOIN G INC L MICROPIGMENTATIO N 6.0 C M OR LES S Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


15775 PUNCH GRAF T HAIR TRANSPLAN T 1-15 PUNCH GRAFTS Y

4






Cosmetic, Plastic & Reconstructive Procedures [In any Setting]

15776 PUNCH GRAFT HAIR TRANSPLANT OVER 15 PUNCH GRAFTS Y

Cosmeti c, Plastic & Reconstructive �Procedures [I n an y Setting]�

15780 DERMABRASIO N TOTA L FACE Y

Cosmeti c, Plastic & Reconstructive Procedures [I n an y Setting]�

� 15781 DERMABRASIO N SEGMENTA L FACE Y

Cosmeti c, Plasti c & Reconstructive �Procedures [I n an y Setting]�

15782 DERMABRASIO N REGIONA L OTHER THA N FACE Y


15783 DERMABRASIO N SUPERFICIA L ANY SITE Y


15788 CHEMICA L PEE L FACIA L EPIDERMA L Y


15789 CHEMICA L PEE L FACIA L DERMAL Y


15792 CHEMICA L PEE L NONFACIA L EPIDERMAL Y


15793 CHEMICA L PEE L NONFACIA L DERMAL Y


15820 BLEPHAROPLASTY LOWER EYELID Y


15821 BLEPHAROPLASTY LOWER EYELID HERNIATED FA T PAD Y


� 15822 BLEPHAROPLASTY UPPER EYELID Y


15823 BLEPHAROPLASTY UPPER EYELID W EXCESSIVE SKIN Y


15824 RHYTIDECTOMY FOREHEAD Y


� 15825 RHYTIDECTOMY NEC K W PLATYSMA L TIGHTENING Y


15826 RHYTIDECTOMY GLABELLAR FROW N LINES Y

Cosmeti c, Plasti c & Reconstructive Procedures [I n an y Setting]�

� 15828 RHYTIDECTOMY CHEE K CHI N AND NEC K Y


15829 RHYTIDECTOMY SMA S FLA P Y


15832 EXCISIO N EXCESSIVE SKI N AND SUBQ TISSUE THIGH Y


15833 EXCISIO N EXCESSIVE SKI N AND SUBQ TISSUE LEG Y


15834 EXCISIO N EXCESSIVE SKI N AND SUBQ TISSUE HIP Y


15835 EXCISIO N EXCESSIVE SKI N AND SUBQ TISSUE BUTTOCK Y

Cosmeti c, Plastic & ReconstructiveProcedures [I n an y Setting]�

� 15836 EXCISIO N EXCESSIVE SKI N AND SUBQ TISSUE ARM Y


� 15837 EX C EXCESSIVE SKI N AND SUBQ TISSUE FOREA RM HAND Y


15838 EX C EXCS V SKI N AND SUBQ TISSUE SUBMENTA L FA T PAD Y


15839 EXCISIO N EXCESSIVE SKI N AND SUBQ TISSUE OTHER AREA Y


15847 EXCISIO N EXCESSIVE SKI N AND SUBQ TISSUE ABDOMEN Y


15876 SUCTIO N ASSISTED LIPECTOMY HEAD AND NEC K Y


15877 SUCTIO N ASSISTED LIPECTOMY TRUNK Y


� 15878 SUCTIO N ASSISTED LIPECTOMY UPPER EXTREMITY Y

Cosmeti c, Plastic & Reconstructive �Procedures [I n an y Setting]

15879 SUCTIO N ASSISTED LIPECTOMY LOWER EXTREMITY Y �


17380 ELECTROLYSI S EPILATIO N EACH 30 MINUTES Y

5







19300

MASTECTOMY GYNECOMASTI A Y P A required , excep t wit h breas t C A Dx' s tha t include ICD1 0 code s: C5 0 - C50.929 , D05.0 0 - D05.92 an d Z85.3 [See D x Codes tab]


19316 MASTOPEXY Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19318 REDUCTIO N MAMMAPLASTY Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19324 MAMMAPLASTY AUGMENTATIO N W O PROSTHETI C IMPLAN T Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19325 MAMMAPLASTY AUGMENTATIO N W PROSTHETI C IMPLAN T Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19328 REMOVA L INTAC T MAMMARY IMPLAN T Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19330 REMOVA L MAMMARY IMPLAN T MATERIAL Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19340 IMM T INS J BRS T PROSTH FLW G MASTOPEXY MAS T RCNSTJ Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19342 DLYD INS J BRS T PROSTH FLW G MASTOPEXY MAS T RCNST J Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19350 NIPPLE AREOL A RECONSTRUCTION Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


19355 CORRECTIO N INVERTED NIPPLES Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 -D05.92 an d Z85.3 [See D x Codes tab]


19396 PREPARATIO N MOULAGE CUSTO M BREAS T IMPLANT Y P A required , excep t wit h brea st C A Dx's tha t include ICD10 code s: C50 - C50.929 , D05.00 - D05.92 an d Z85.3 [See D x Codes tab]


30400 RHIN P PRI M LA T AND ALAR CRTLG S AND ELVT N NASA L TI Y


30410 RHINP PRIM COMPLETE XTRNL PARTS Y

Cosmeti c, Plastic & Reconstructive Procedures [I n an y Setting]

30420 RHINOPLASTY PRIMARY W MAJOR SEPTAL REPAIR Y


30430 RHINOPLASTY SECONDARY MINOR REVISION Y


30435 RHINOPLASTY SECONDARY INTERMEDIATE REVISION Y


30450 RHINOPLASTY SECONDARY MAJOR REVISION Y


30460 RHINP DFRM W COLUM LNGTH TIP ONLY Y


30462 RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT Y


67904 RPR BLEPHAROPTOSIS LEVATOR RESCJ ADVMNT XTRNL Y


67906 RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING Y


67908 RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ Y


69300 OTOPLASTY PROTRUDING EAR W WO SIZE RDCTJ Y

Durable Medica l Equipmen t (DME) E0650 Pneumatic compressor, non-segmental home model Y Durable Medical Equipment (DME) E0651 Pneumatic compressor , segmenta l home mode l without calibrated

gradien t pressure Y

Durable Medical Equipment (DME) E0673 Segmental gradient pressure pneumatic appliance, half leg Y Durable Medical Equipment (DME) E0731 Form fitting conductive garment for delivery of tens or nmes (with

conductive fibers separate d from the patient's ski n b y layers o f fabric)

Y Y

Durable Medical Equipment (DME) E0740 Non-implanted pelvic floor electrical stimulator, complete system Y Y

Durable Medical Equipment (DME) E0947 Fracture frame, attachments for complex pelvic traction Y Y Durable Medical Equipment (DME) E0948 Fracture frame, attachments for complex cervical traction Y Y

6






Durable Medica l Equipmen t (DME) A5514 Fo r diabeti cs only , multiple densit y insert , made b y dire ct carvin g wit h cam technolog y from a rectifie d ca d mode l create d from a digitize d sca n o f the patient , tota l conta ct wit h patient' s foot , includin g arch , base laye r minimum o f 3/16 in ch materia l o f shore a 35 duromete r (o r higher) , includes ar ch fille r an d othe r shapin g material , custom fabricated , each

Y

Durable Medica l Equipmen t (DME) A7025 Hig h frequen cy ches t wal l oscillatio n system vest , replacemen t for use wit h patien t owne d equipment , each

Y

Durable Medica l Equipmen t (DME) A8003 Helmet , protective , hard , custom fabricated , include s all components an d accessories

Y Y

Durable Medica l Equipmen t (DME) A8004 Soft interface for helmet, replacement only Y Y Durable Medica l Equipmen t (DME) A9274 Externa l ambulator y insuli n deliver y system , disposable , each ,

includes al l supplies an d accessories Y

Durable Medica l Equipmen t (DME) A9276 Sensor ; invasive (e.g. , subcutaneous) , disposable , fo r use with interstitia l continuous glucose monitorin g system , 1 uni t = 1 da y supply

Y

Durable Medica l Equipmen t (DME) A9277 DIAB ONLY MX DEN INSRT DIRECT CARV CUSTOM FAB EA Y Durable Medica l Equipmen t (DME) A9278 Receiver (monitor); external, for use with interstitial continuous

glucose monitorin g system Y

Durable Medica l Equipmen t (DME) A9901 Dme delivery, set up, and/or dispensing service component of anothe r hcpcs code

Y

Durable Medica l Equipmen t (DME) C1839 Iris prosthesis Y Durable Medical Equipment (DME) C2624 HI FREQ CHST WALL OSCILLAT SYS VEST REPL PT OWND Y Durable Medical Equipment (DME) E0193 Powered air flotation bed (low air loss therapy) Y Y Durable Medical Equipment (DME) E0194 Air fluidized bed Y Durable Medical Equipment (DME) E0217 EXTERNAL AMB INSULIN DEL SYSTEM DISPOSABLE EA Y Y Durable Medical Equipment (DME) E0248 SENSOR;INVSV DISP INTRSTL CONT GLU MON SYS 1U EQ 1D Y Y Code applicable to Medicaid only Durable Medical Equipment (DME) E0255 TRANSMITTER; EXT INTERSTITIAL CONT GLU MON SYS Y Code applicable to Medicaid only Durable Medical Equipment (DME) E0256 RECEIVER MON; EXT INTERSTITIAL CONT GLU MON SYS Y Code applicable to Medicaid only Durable Medical Equipment (DME) E0260 DME DEL SET UP AND DISPNS SRVC CMPNT ANOTH HCPCS Y Durable Medical Equipment (DME) E0261 IMPL WIRELESS PULM ARTERY PRESS SENSOR DEL CATH Y Durable Medical Equipment (DME) E0265 Hospita l bed , tota l electric (head , foot , an d heigh t adjustments) ,

wit h an y type side rails , wit h mattress Y

Durable Medical Equipment (DME) E0266 AIR FLUIDIZED BED Y Durable Medical Equipment (DME) E0277 Powered pressure-reducing air mattress Y Durable Medical Equipment (DME) E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress Y

Durable Medical Equipment (DME) E0293 HOS BED VARIBL HT W ANY TYPE SIDE RAIL W MATTRSS Y Durable Medical Equipment (DME) E0294 HOS BED VARIBL HT ANY TYPE SIDE RAIL W O MATTRSS Y Durable Medical Equipment (DME) E0295 HOS BED SEMI-ELEC W ANY TYPE SIDE RAIL W MATTRSS Y Durable Medical Equipment (DME) E0296 HOS BED SEMI-ELEC ANY TYPE SIDE RAIL W O MATTRSS Y Durable Medical Equipment (DME) E0297 HOSP BED TOT ELEC W ANY TYPE SIDE RAIL W MATTRSS Y Durable Medical Equipment (DME) E0300 HOS BED TOT ELEC ANY TYPE SIDE RAIL W O MATTRSS Y Durable Medical Equipment (DME) E0301 POWERED PRESSURE-REDUCING AIR MATTRESS Y Durable Medical Equipment (DME) E0302 HOSP BED VARIBL HT HI-LO W O SIDE RAIL W MATTRSS Y Durable Medical Equipment (DME) E0303 HOS BED VARIBL HT HI-LO W O SIDE RAIL NO MATTRSS Y Durable Medical Equipment (DME) E0304 HOSPITAL BED SEMI-ELEC W O SIDE RAILS W MATTRSS Y Durable Medical Equipment (DME) E0328 HOSP BED SEMI-ELEC W O SIDE RAILS W O MATTRSS Y Durable Medical Equipment (DME) E0329 HOSPITAL BED TOTAL ELEC W O SIDE RAILS W MATTRSS Y Durable Medical Equipment (DME) E0371 HOSP BED TOTAL ELEC W O SIDE RAILS W O MATTRSS Y Durable Medical Equipment (DME) E0372 PED CRIB HOS GRADE FULLY ENC W WO TOP ENC Y Durable Medical Equipment (DME) E0373 HOS BED HEVY DUTY XTRA WIDE W WT CAPACTY OVER 350 PDS Y

Durable Medical Equipment (DME) E0433 HOS BED XTRA HEVY DUTY WT CAP OVER 600 PDS W O MTTRSS Y Y

Durable Medical Equipment (DME) E0434 HOS BED HEVY DUTY W WT CAP OVER 350 PDS UNDER EQ TO 600 Y Y

Durable Medical Equipment (DME) E0435 HOS BED EXTRA HEAVY DUTY WT CAP OVER 600 PDS MATTRSS Y Y

Durable Medical Equipment (DME) E0444 HOSPITAL BED PEDIATRIC MANUAL INCLUDES MATTRESS Y Y Durable Medical Equipment (DME) E0462 NONPWR ADV PRSS RDUC OVRLAY MATTRSS STD LEN AND WDTH Y

Durable Medical Equipment (DME) E0465 PWR AIR OVRLAY MATTRSS STD MATTRSS LENGTH AND WIDTH Y

7






Durable Medical Equipment (DME) E0466 HOME VENTILATOR ANY TYPE USED W NON-INVASV INTF Y Durable Medical Equipment (DME) E0467 Home ventilator, multi-function respiratory device, also performs

any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions

Y

Durable Medica l Equipmen t (DME) E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airwa y pressure device)

Y Y

Durable Medica l Equipmen t (DME) E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

Y Y

Durable Medica l Equipmen t (DME) E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermitten t assis t device wit h continuou s positive airwa y pressur e device)

Y Y

Durable Medical Equipment (DME) E0481 PRTB O C LQD 1 MO SPL EQ 1 U PRSC AMT R N EXCD 4LPM Y Durable Medical Equipment (DME) E0483 ROCKING BED WITH OR WITHOUT SIDE RAILS Y Durable Medical Equipment (DME) E0601 HOME VENTILATOR ANY TYPE USED W INVASIVE INTF Y Durable Medical Equipment (DME) E0625 HOME VENTILATOR ANY TYPE USED W NON-INVASV INTF Y Y Durable Medical Equipment (DME) E0630 Patient lift, hydraulic or mechanical, includes any seat, sling,

strap(s) , o r pad(s) Y Y

Durable Medical Equipment (DME) E0635 Patient lift, electric, with seat or sling Y Y Durable Medical Equipment (DME) E0638 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM EA Y Y Durable Medical Equipment (DME) E0640 Patient lift, fixed system, includes all components/accessories Y Y Durable Medical Equipment (DME) E0641 Standing frame/table system, multi-position (e.g., 3-way stander),

an y size includin g pediatri c, wit h o r withou t wheels Y Y

Durable Medical Equipment (DME) E0650 PNEUMATIC COMPRESSOR NONSEGMENTAL HOME MODEL Y Durable Medical Equipment (DME) E0651 PNEUMAT COMPRS SEG HOM MDL NO CALBRTD GRDNT PRSS Y

Durable Medical Equipment (DME) E0652 PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH Y Durable Medical Equipment (DME) E0656 SEG PNEUMAT APPLIANCE USE W PNEUMAT COMPRS TRUNK Y Durable Medical Equipment (DME) E0656 Segmental pneumatic appliance for use with pneumatic Y Durable Medical Equipment (DME) E0657 SEG PNEUMAT APPLIANCE USE W PNEUMAT COMPRS CHEST Y Durable Medical Equipment (DME) E0657 Segmental pneumatic appliance for use with pneumatic Y Durable Medical Equipment (DME) E0667 SEG PNEUMAT APPLINC W PNEUMAT COMPRS FULL LEG Y Durable Medical Equipment (DME) E0667 Segmental pneumatic appliance for use with pneumatic Y Durable Medical Equipment (DME) E0668 SEG PNEUMAT APPLINC W PNEUMAT COMPRS FULL ARM Y Durable Medical Equipment (DME) E0668 Segmental pneumatic appliance for use with pneumatic Y Durable Medical Equipment (DME) E0670 SEG PNEU APPLINC PNEU COMPRS IN 2 FULL LEGS TRNK Y Durable Medica l Equipmen t (DME) E0670 Segmenta l pneumati c appliance fo r use wit h pneumati c

compressor , integrated , 2 ful l legs an d trunk Y

Durable Medical Equipment (DME) E0671 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC FULL LEG Y

Durable Medical Equipment (DME) E0671 Segmental gradient pressure pneumatic appliance, full leg Y

Durable Medical Equipment (DME) E0672 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC FULL ARM Y

Durable Medical Equipment (DME) E0672 Segmental gradient pressure pneumatic appliance, full arm Y

Durable Medical Equipment (DME) E0673 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC HALF LEG Y

Durable Medical Equipment (DME) E0675 PNEUMAT COMPRS DEVC HI PRSS RAPID INFLATION DEFL Y Durable Medical Equipment (DME) E0675 Pneumatic compression device, high pressure, rapid Y Durable Medical Equipment (DME) E0676 INTERMITTENT LIMB COMPRESSION DEVICE NOS Y

Durable Medical Equipment (DME) E0691 UV LIGHT TX SYS BULB LAMP TIMER; TX 2 SQ FT LESS Y Durable Medical Equipment (DME) E0692 UV LT TX SYS PANL W BULB LAMP TIMER 4 FT PANEL Y Durable Medical Equipment (DME) E0693 UV LT TX SYS PANL W BULBS LAMPS TIMER 6 FT PANEL Y Durable Medical Equipment (DME) E0694 UV MX DIR LT TX SYS 6 FT CABINET W BULB LAMP TMR Y Durable Medical Equipment (DME) E0744 Neuromuscular stimulator for scoliosis Y Y Durable Medical Equipment (DME) E0747 OSTOGNS STIM ELEC NONINVASV OTH THAN SP APPLIC Y

8






Durable Medical Equipment (DME) E0748 OSTOGNS STIMULATOR ELEC NONINVASV SPINAL APPLIC Y Durable Medical Equipment (DME) E0749 OSTEOGENESIS STIMULATOR ELEC SURGICALLY IMPL Y Durable Medical Equipment (DME) E0760 OSTOGNS STIM LOW INTENS ULTRASOUND NON-INVASV Y Durable Medical Equipment (DME) E0762 TRANSCUT ELEC JOINT STIM DEVC SYS INCL ALL ACCSS Y Durable Medical Equipment (DME) E0764 FUNC NEUROMUSC STIM MUSC AMBUL CMPT CNTRL SC INJ Y Durable Medical Equipment (DME) E0766 ELEC STIM DVC U CANCER TX INCL ALL ACC ANY TYPE Y Durable Medical Equipment (DME) E0782 INFUSION PUMP IMPLANTABLE NON-PROGRAMMABLE Y Durable Medical Equipment (DME) E0783 INFUSION PUMP SYSTEM IMPLANTABLE PROGRAMMABLE Y Durable Medical Equipment (DME) E0784 EXTERNAL AMBULATORY INFUSION PUMP INSULIN Y Durable Medical Equipment (DME) E0785 IMPLANTABLE INTRASPINL CATHETER USED W PUMP-REPL Y Durable Medical Equipment (DME) E0786 IMPLANTABLE PROGRAMMABLE INFUSION PUMP REPL Y Durable Medical Equipment (DME) E0787 External ambulatory infusion pump, insulin, dosage rate

adjustmen t usin g therapeutic continuous glucose sensing Y

Durable Medical Equipment (DME) E0849 TRACTION EQP CERV FREESTAND STAND FRME PNEUMATIC Y Durable Medical Equipment (DME) E0855 CERVICAL TRACTION EQUIP NOT RQR ADD STAND FRAME Y Durable Medical Equipment (DME) E0983 MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WC Y Durable Medical Equipment (DME) E0984 MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WC Y Durable Medical Equipment (DME) E0986 MNL WHEELCHAIR ACSS PUSH-RIM ACT PWR ASSIST SYS Y Durable Medical Equipment (DME) E0988 MANUAL WC ACCESSORY LEVR-ACTIVATD WHL DRIVE PAIR Y Durable Medical Equipment (DME) E1002 WHEELCHAIR ACCESS POWER SEATING SYSTEM TILT ONLY Y Durable Medical Equipment (DME) E1003 WC ACSS PWR SEAT SYS RECLINE W O SHEAR RDUC Y Durable Medical Equipment (DME) E1004 WC ACSS PWR SEAT SYS RECLINE W MECH SHEAR RDUC Y Durable Medical Equipment (DME) E1005 WC ACSS PWR SEAT SYS RECLINE W PWR SHEAR RDUC Y Durable Medical Equipment (DME) E1006 WC ACSS PWR SEAT SYS TILT AND RECLINE NO SHEAR RDUC Y Durable Medical Equipment (DME) E1007 WC ACSS PWR SEAT TILT AND RECLINE MECH SHEAR RDUC Y Durable Medical Equipment (DME) E1008 WC ACSS PWR SEAT TILT AND RECLINE W PWR SHEAR RDUC Y Durable Medical Equipment (DME) E1010 WC ACCSS ADD PWR SEAT SYS PWR LEG ELEV SYS PAIR Y Durable Medical Equipment (DME) E1011 Modificatio n to pediatric size wheelchair , widt h adjustmen t

package (no t to be dispense d wit h initia l chair) Y Y

Durable Medical Equipment (DME) E1012 WC ACCSS PWR SEAT SYS CNTR MNT PWR ELEV LEG EA Y Durable Medical Equipment (DME) E1014 RECLIN BACK ADDITION PEDIATRIC SIZE WHEELCHAIR Y Durable Medical Equipment (DME) E1020 RESIDUAL LIMB SUPPORT SYSTEM WHEELCHAIR ANY TYPE Y Durable Medical Equipment (DME) E1028 WHEELCHAIR ACCESSORY, MANUAL SWING AWAY, RETRACTABLE

OR REMOVABLE MOUNTIN G HARDWARE FOR JOYSTICK , OTHER CONTRO L INTERFACE OR POSITIONIN G ACCESSOR

Y

Durable Medical Equipment (DME) E1029 WHEELCHAIR ACCESSORY VENTILATOR TRAY FIXED Y Durable Medical Equipment (DME) E1030 WHEELCHAIR ACCESSORY VENTILATOR TRAY GIMBALED Y Durable Medical Equipment (DME) E1035 MULTI-PSTN PT TRNSF SYS W SEAT PT WT UNDER EQ 300 LBS Y

Durable Medical Equipment (DME) E1036 MULTI-PSTN PT TRNSF SYS EXTRA WIDE PT OVER 300 LBS Y Durable Medical Equipment (DME) E1037 Transport chair, pediatric size Y Y Durable Medical Equipment (DME) E1050 Fully-reclining wheelchair, fixed full length arms, swing away

detachable elevatin g le g rests Y Y

Durable Medical Equipment (DME) E1060 Fully-reclining wheelchair, detachable arms, desk or full length, swin g awa y detachable elevatin g legrests

Y Y

Durable Medical Equipment (DME) E1070 Fully-reclining wheelchair, detachable arms (desk or full length) swin g awa y detachable footrest

Y Y

Durable Medical Equipment (DME) E1161 MANUAL ADULT SIZE WHEELCHAIR INCLUDES TILT SPACE Y Durable Medical Equipment (DME) E1225 WHLCHAIR ACCESS MANUAL SEMIRECLINING BACK EACH Y Durable Medical Equipment (DME) E1226 WHLCHAIR ACCESS MANUAL FULL RECLINING BACK EACH Y Durable Medical Equipment (DME) E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR Y Durable Medical Equipment (DME) E1229 Wheelchair, pediatric size, not otherwise specified Y Y Durable Medical Equipment (DME) E1230 PWR OPERATED VEH SPEC BRAND NAME AND MODEL NUMBER Y

Durable Medical Equipment (DME) E1232 WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W SEAT SYS Y Durable Medical Equipment (DME) E1233 WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W O SEAT Y Durable Medical Equipment (DME) E1234 WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W O SEAT Y Durable Medical Equipment (DME) E1235 WHLCHAIR PED SIZE RIGD ADJUSTBL W SEATING SYSTEM Y Durable Medical Equipment (DME) E1236 WHLCHAIR PED SIZE FOLD ADJUSTBL W SEATING SYSTEM Y Durable Medical Equipment (DME) E1237 WHLCHAIR PED SZ RIGD ADJUSTBL W O SEATING SYSTEM Y Durable Medical Equipment (DME) E1238 WHLCHAIR PED SZ FOLD ADJUSTBL W O SEATING SYSTEM Y Durable Medical Equipment (DME) E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR Y Durable Medical Equipment (DME) E1298 SPECIAL WHLCHAIR SEAT DEPTH AND OR WIDTH CONSTRUCT Y Durable Medical Equipment (DME) E1310 WHIRLPOOL NONPORTABLE Y

9






Durable Medica l Equipmen t (DME) E1700 JAW MOTIO N REHABILITATIO N SYSTE M Y Durable Medica l Equipmen t (DME) E2201 MN L W C ACS S NONSTD SEA T WDTH G RT TH N EQ 20 I N AND

UNDER Y

Durable Medica l Equipmen t (DME) E2202 MANUA L W C ACS S NONSTD SEA T FRME WIDTH 24-27 I N Y Durable Medica l Equipmen t (DME) E2203 MANUA L W C ACS S NONSTD SEA T FRME DEPTH 20 UNDER 22 I N Y

Durable Medica l Equipmen t (DME) E2204 MANUA L W C ACS S NONSTD SEA T FRME DEPTH 22-25 I N Y Durable Medica l Equipmen t (DME) E2218 Manua l wheelchai r accessory , foam propulsio n tire , an y size , each Y Y

Durable Medica l Equipmen t (DME) E2227 MANUA L W C ACCES S GEAR REDUCTIO N DRIVE WHEE L EACH Y Durable Medica l Equipmen t (DME) E2228 MN L W C ACCES S WHEE L BRAKIN G SY S AND LOC K COMPLETE E A Y

Durable Medica l Equipmen t (DME) E2291 BAC K PLANAR PED S Z W C INC L FI X ATTCHIN G HARDWARE Y Durable Medica l Equipmen t (DME) E2292 SEA T PLANAR PED S Z W C INC L FI X ATTCHIN G HARDWARE Y Durable Medica l Equipmen t (DME) E2293 BAC K CONTOURED PED W C INC L FI X ATTCH HARDWARE Y Durable Medica l Equipmen t (DME) E2294 SEA T CONTOURED PED W C INC L FI X ATTCH HARDWARE Y Durable Medica l Equipmen t (DME) E2295 MN L W C ACCES S PED SIZE W C DYNAMI C SEATIN G FRAME Y Durable Medica l Equipmen t (DME) E2300 WHEE L CHAIR ACCESSORY - PWR SEA T ELEVATIO N SYS Y Durable Medica l Equipmen t (DME) E2310 PWR W C ACS S ELE C CNC T BETW N W C CNTRLLER AND ONE PWR Y

Durable Medica l Equipmen t (DME) E2311 PWR W C ACS S ELE C CNC T BETW N W C CNTRLLER AND TW O MORE Y

Durable Medica l Equipmen t (DME) E2312 POWER W C ACCES S HAND OR CHI N CONTRO L INTERFACE Y Durable Medica l Equipmen t (DME) E2313 POWER W C ACCES S HARNES S UPGRADE EX P CONTROLLR EA Y Durable Medica l Equipmen t (DME) E2321 PWR W C ACS S HND CNT RL REMO T JOYSTC K N O PRPRTN L Y Durable Medica l Equipmen t (DME) E2322 PWR W C ACS S HND CNT RL M X MECH SWTCH N O PRPRTN L Y Durable Medica l Equipmen t (DME) E2323 Powe r wheelchai r accessory , specialt y joysti ck handle fo r hand

contro l interface , prefabricated Y Y

Durable Medica l Equipmen t (DME) E2324 Powe r wheelchai r accessory , chi n cu p fo r chi n contro l interface Y Y

Durable Medica l Equipmen t (DME) E2325 PWR W C ACS S SI P AND PUF F INTERFCE NONPROPRTNAL Y Durable Medica l Equipmen t (DME) E2326 PWR W C ACS S BREATH TUBE KI T SI P AND PUF F INTERFCE Y Durable Medica l Equipmen t (DME) E2327 PWR W C ACS S HEAD CNT RL INTERFCE MECH PROPRTNA L Y Durable Medica l Equipmen t (DME) E2328 PWR W C ACS S HEAD CNT RL EX T CNT RL ELE C PRPRTN L Y Durable Medica l Equipmen t (DME) E2329 PWR W C ACS S HEAD CNT RL CNT C SWTCH MECH NOPRPRTNL Y Durable Medica l Equipmen t (DME) E2330 PWR W C ACCS S HEAD PRO X SWITCH MECH NONPRPRTN L Y Durable Medica l Equipmen t (DME) E2331 Powe r wheelchai r accessory , attendan t control , proportional ,

includin g al l relate d electroni cs an d fixe d mountin g hardware Y Y

Durable Medica l Equipmen t (DME) E2340 POWER W C ACCES S NONSTAND SEA T FRAME WD 20-23 I N Y Durable Medica l Equipmen t (DME) E2341 PWR W C ACS S NONSTD SEA T FRME WIDTH 24-27 I N Y Durable Medica l Equipmen t (DME) E2342 PWR W C ACS S NONSTD SEA T FRME DEPTH 20 21 I N Y Durable Medica l Equipmen t (DME) E2343 PWR W C ACS S NONSTD SEA T FRME DEPTH 22-25 IN Y Durable Medica l Equipmen t (DME) E2351 PWR W C ACS S ELE C INTERFCE OPERATE SPCH GE N DEV C Y Durable Medica l Equipmen t (DME) E2359 Powe r wheelchai r accessory , grou p 34 seale d lea d aci d battery ,

ea ch (e.g. , ge l cell , absorbe d glas s mat) Y Y

Durable Medica l Equipmen t (DME) E2360 Powe r wheelchai r accessory , 22n f non-seale d lea d aci d battery , each

Y Y

Durable Medica l Equipmen t (DME) E2361 PWR W C ACS S 22N F SEALED LEAD ACID BATTRY EA Y Durable Medica l Equipmen t (DME) E2362 Powe r wheelchai r accessory , grou p 24 non-seale d lea d aci d battery ,

each Y Y

Durable Medica l Equipmen t (DME) E2363 Powe r wheelchai r accessory , grou p 24 seale d lea d aci d battery , ea ch (e.g. , ge l cell , absorbe d glassmat)

Y Y

Durable Medica l Equipmen t (DME) E2364 Powe r wheelchai r accessory , u-1 non-seale d lea d aci d battery , each Y Y

Durable Medica l Equipmen t (DME) E2365 Powe r wheelchai r accessory , u-1 seale d lea d aci d battery , each (e.g. , ge l cell , absorbe d glassmat)

Y Y

Durable Medica l Equipmen t (DME) E2366 PWR W C ACS S BATTRY CHRGR 1 MODE W ONLY 1 BATTRY Y Durable Medica l Equipmen t (DME) E2367 PWR W C ACS S BAT T CHRGR DU L MODE W EITHER BAT T EA Y Durable Medica l Equipmen t (DME) E2368 POWER WHEELCHAIR CMPN T MOTOR REPLACEMEN T ONLY Y Durable Medica l Equipmen t (DME) E2369 POWER W C CMPNN T DRIVE WHEE L GEAR BO X REP L ONLY Y Durable Medica l Equipmen t (DME) E2370 PWR W C COM P IN T DR WH L MTR AND GR BO X COMB REP L ONLY Y

Durable Medica l Equipmen t (DME) E2371 Powe r wheelchai r accessory , grou p 27 seale d lea d aci d battery , (e.g. , ge l cell , absorbe d glassmat) , each

Y Y

10






Durable Medica l Equipmen t (DME) E2372 Powe r wheelchai r accessory , grou p 27 non-seale d lea d aci d battery , each

Y Y

Durable Medica l Equipmen t (DME) E2373 PWR W C MINI-PROPORTIONA L COMPAC T REMOTE JOYSTIC K Y Durable Medica l Equipmen t (DME) E2374 PWR W C STANDARD REMOTE JOYSTIC K REPLACEMEN T ONLY Y Durable Medica l Equipmen t (DME) E2375 PWR W C NONEXPNDABLE CONTROLLER REPLACEMEN T ONLY Y Durable Medica l Equipmen t (DME) E2376 PWR W C EXPANDABLE CONTROLLER REPLACEMEN T ONLY Y Durable Medica l Equipmen t (DME) E2377 PWR W C EXPANDABLE CONTROLLER UPGRADE INI T ISSUE Y Durable Medica l Equipmen t (DME) E2378 POWER WHEELCHAIR COMPONEN T ACTUATOR REPLACE ONLY Y Durable Medica l Equipmen t (DME) E2381 Powe r wheelchai r accessory , pneumatic drive whee l tire , any size ,

replacemen t only , each Y Y

Durable Medica l Equipmen t (DME) E2382 Powe r wheelchai r accessory , tube fo r pneumatic drive whee l tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2383 Powe r wheelchai r accessory , insert fo r pneumatic drive whee l tire (removable) , an y type , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2384 Powe r wheelchai r accessory , pneumatic caste r tire , any size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2385 Powe r wheelchai r accessory , tube fo r pneumatic caste r tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2386 Powe r wheelchai r accessory , foam fille d drive whee l tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2387 Powe r wheelchai r accessory , foam fille d caste r tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2388 Powe r wheelchai r accessory , foam drive whee l tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2389 Powe r wheelchai r accessory , foam caste r tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2390 Powe r wheelchai r accessory , soli d (rubber/plasti c) drive whee l tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2391 Powe r wheelchai r accessory , soli d (rubber/plasti c) caste r tire (removable) , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2392 Powe r wheelchai r accessory , soli d (rubber/plasti c) caste r tire with integrate d wheel , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2394 Powe r wheelchai r accessory , drive whee l excludes tire , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2395 Powe r wheelchai r accessory , caste r whee l excludes tire , any size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2396 Powe r wheelchai r accessory , caste r fork , an y size , replacemen t only , each

Y Y

Durable Medica l Equipmen t (DME) E2397 POWER WHLCHAIR ACCESSORY LITHIUM-BASED BATTRY E A Y Durable Medica l Equipmen t (DME) E2398 Wheelchai r accessory , dynamic positioning hardware fo r back Y

Durable Medica l Equipmen t (DME) E2402 Negative pressure woun d therap y electrica l pump , stationar y or portable

Y Y

Durable Medica l Equipmen t (DME) E2500 SPEECH GE N DEV C DIGITIZED UNDER EQ 8 MIN S RE C TIME Y Durable Medica l Equipmen t (DME) E2502 SPCH GE N DEV C DIGTIZD OVER 8 MIN S LES S TH N EQ 20 MIN S RE C Y

Durable Medica l Equipmen t (DME) E2504 SPCH GE N DEV C DIGTIZD OVER 20 MIN S UNDER EQ 40 MIN S RE C Y

Durable Medica l Equipmen t (DME) E2506 SPEECH GE N DEVICE DIGITIZED OVER 40 MIN S RE C TIME Y Durable Medica l Equipmen t (DME) E2508 SPCH GE N DEV C SYNTHSIZD REQ MES S SPEL L AND CNTC T Y Durable Medica l Equipmen t (DME) E2510 SPCH GE N DEV C SYNTHESIZD M X METH MES S AND DEV C ACCS S Y

Durable Medica l Equipmen t (DME) E2511 SPEECH GE N SOFTWARE PRO G P C PE RS DIGITA L ASSIS T Y Durable Medica l Equipmen t (DME) E2512 Accessor y fo r spee ch generatin g device , mountin g system Y Y Durable Medica l Equipmen t (DME) E2599 Accessor y fo r spee ch generatin g device , no t otherwise classified Y Y

Durable Medica l Equipmen t (DME) E2609 CUSTO M FABRICATED WHEELCHAIR SEA T CUSHIO N SIZE Y Durable Medica l Equipmen t (DME) E2617 CST M FAB W C BAC K CUSH N ANY S Z ANY MOUN T HARDWARE Y Durable Medica l Equipmen t (DME) E2626 W C ACCES S SHLDR ELB MOBI L A RM SUP P W C ADJUSTBLE Y Durable Medica l Equipmen t (DME) E2627 W C ACCES S SHLDR ELB M A RM SUP P ADJUSTB L RANCH O Y Durable Medica l Equipmen t (DME) E2628 W C ACCES S SHLDR ELB MOBI L A RM SUP P W C RECLININ G Y Durable Medica l Equipmen t (DME) E2629 W C ACCES S SHLDR ELB M A RM SUP P FRICTIO N A RM SUP P Y Durable Medica l Equipmen t (DME) E2630 W C ACCES S SHLDR ELB MOBI L MONOSUS P A RM HAND SUP P Y Durable Medica l Equipmen t (DME) E2631 W C ACCES S ADD MOBILE A RM SUPPO RT ELE V PRO X A RM Y

11




SC P A Required

Matrix Service Category Code Definition SC State Exception Notes

Durable Medica l Equipmen t (DME) E8000 Gai t trainer , pediatri c size , posterio r support , includes all accessories an d components

Y Y

Durable Medica l Equipmen t (DME) E8001 Gai t trainer , pediatri c size , uprigh t support , includes al l accessories an d components

Y Y

Durable Medica l Equipmen t (DME) E8002 Gai t trainer , pediatri c size , anterio r support , includes al l accessories an d components

Y Y

Durable Medica l Equipmen t (DME) K0002 Standar d hem i (low seat ) wheelchair Y Y Durable Medica l Equipmen t (DME) K0003 Lightweigh t wheelchair Y Y Durable Medica l Equipmen t (DME) K0004 Hig h strength , lightweigh t wheelchair Y Y Durable Medica l Equipmen t (DME) K0005 Ultralightweigh t wheelchair Y Y Durable Medica l Equipmen t (DME) K0006 Heav y dut y wheelchair Y Y Durable Medica l Equipmen t (DME) K0007 Extr a heav y dut y wheelchair Y Y Durable Medica l Equipmen t (DME) K0008 CUSTO M MANUA L WHEELCHAIR BASE Y Durable Medica l Equipmen t (DME) K0009 OTHER MANUA L WHEELCHAIR BASE Y Durable Medica l Equipmen t (DME) K0010 STANDARD-WEIGH T FRAME MOTORIZED POWER WHEELCHAIR Y

Durable Medica l Equipmen t (DME) K0011 STD-W T FRME MOTRIZD PWR WHLCHAIR W PRO G CNTRL Y Durable Medica l Equipmen t (DME) K0012 LIGHTWEIGH T PORTABLE MOTORIZED POWER WHEELCHAIR Y Durable Medica l Equipmen t (DME) K0014 OTHER MOTORIZED POWER WHEELCHAIR BASE Y Durable Medica l Equipmen t (DME) K0108 OTHER ACCESSORIES Y Durable Medica l Equipmen t (DME) K0553 SUPPLY ALLOW FOR T X CGM1 M O SP L EQ 1 U O F SERVICE Y Durable Medica l Equipmen t (DME) K0554 RECEIVER DEDICATED FOR USE W THERAPEUTI C GC M SYS Y Durable Medica l Equipmen t (DME) K0606 AUT O EX T DEFIB W INTGR EC G ANALY GARMEN T TYPE Y Durable Medica l Equipmen t (DME) K0733 Powe r wheelchai r accessory , 12 to 24 am p hou r seale d lea d acid

battery , ea ch (e.g. , ge l cell , absorbe d glassmat) Y Y

Durable Medica l Equipmen t (DME) K0800 PWR O P VEH G RP 1 STD P T W T CA P T O AND INC L 300 LBS Y Durable Medica l Equipmen t (DME) K0801 PWR O P VEH G RP 1 HEAVY DUTY P T 301 T O 450 LBS Y Durable Medica l Equipmen t (DME) K0802 PWR O P VEH G RP 1 VERY HEAVY DUTY P T 451-600 LBS Y Durable Medica l Equipmen t (DME) K0806 PWR O P VEH G RP 2 STD P T W T CA P T O AND INC L 300 LBS Y Durable Medica l Equipmen t (DME) K0807 PWR O P VEH G RP 2 HEAVY DUTY P T 301 T O 450 LBS Y Durable Medica l Equipmen t (DME) K0808 PWR O P VEH G RP 2 VERY HEAVY DUTY P T 451-600 LBS Y Durable Medica l Equipmen t (DME) K0813 PWR W C G RP 1 STD PO RT SLIN G SEA T P T T O 300 LB S Y Durable Medica l Equipmen t (DME) K0814 PWR W C G RP 1 STD PO RT CAP T CHAIR P T T O 300 LB S Y Durable Medica l Equipmen t (DME) K0815 PWR W C G RP 1 STD SLIN G SEA T P T U P T O AND EQ 300 LB S Y Durable Medica l Equipmen t (DME) K0816 PWR W C G RP 1 STD CAPTAIN S CHAIR P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0820 PWR WC GRP 2 STD PORT SLING SEAT PT TO AND EQ 300 LBS Y

Durable Medica l Equipmen t (DME) K0821 PWR WC GRP 2 STD PORT CAPT CHAIR PT TO AND EQ 300 LBS Y

Durable Medica l Equipmen t (DME) K0822 PWR W C G RP 2 STD SLIN G SEA T P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0823 PWR W C G RP 2 STD CAPTAIN S CHAIR P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0824 PWR W C G RP 2 HEVY DUTY SLIN G SEA T P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0825 PWR W C G RP 2 HEVY DUTY CAP T CHAIR P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0826 PWR W C G RP 2 VRY HVY DTY SLN G SEA T P T 451-600 LB Y Durable Medica l Equipmen t (DME) K0827 PWR W C G RP 2 VRY HVY DTY CAP T CHR P T 451-600 LBS Y Durable Medica l Equipmen t (DME) K0828 PWR W C G RP 2 XT RA HVY DUTY SLIN G SEA T P T 601LB OR GRT Y Durable Medica l Equipmen t (DME) K0829 PWR W C G RP 2 XT RA HVY DUTY CHAIR P T 601 LB S OR GRT Y Durable Medica l Equipmen t (DME) K0830 PWR WC GRP 2 STD SEAT ELEV SLING PT TO AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0831 PWR W C G RP 2 STD SEA T ELE V CA P CHR P T T O 300 LB Y Durable Medica l Equipmen t (DME) K0835 PWR W C G RP 2 STD 1 PWR SLIN G SEA T P T T O 300 LB S Y Durable Medica l Equipmen t (DME) K0836 PWR W C G RP 2 STD 1 PWR CAP T CHAIR P T T O 300 LB S Y Durable Medica l Equipmen t (DME) K0837 PWR W C G RP 2 HVY 1 PWR SLIN G SEA T P T 301-450 LB S Y Durable Medica l Equipmen t (DME) K0838 PWR W C G RP 2 HVY 1 PWR CAP T CHAIR P T 301-450 LB S Y Durable Medica l Equipmen t (DME) K0839 PWR W C G RP 2 VRY HVY 1 PWR SLIN G P T 451-600 LB S Y Durable Medica l Equipmen t (DME) K0840 PWR W C G RP 2 XT RA HVY 1 PWR SLIN G P T 601 LB S OR G RT Y Durable Medica l Equipmen t (DME) K0841 PWR W C G RP 2 M X PWR SLIN G SEA T P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0842 PWR W C G RP 2 STD M X PWR CAP T CHR P T T O AND EQ 300 LBS Y

Durable Medica l Equipmen t (DME) K0843 PWR W C G RP 2 HVY M X PWR SLN G SEA T P T 301-450 LB S Y Durable Medica l Equipmen t (DME) K0848 PWR W C G RP 3 STD SLIN G SEA T P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0849 PWR W C G RP 3 STD CAPTAI N CHAIR P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0850 PWR W C G RP 3 HVY DUTY SLIN G SEA T P T 301-450 LB S Y Durable Medica l Equipmen t (DME) K0851 PWR W C G RP 3 HVY DUTY CAP T CHAIR P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0852 PWR W C G RP 3 V HVY DUTY SLIN G SEA T P T 451-600 LB Y Durable Medica l Equipmen t (DME) K0853 PWR W C G RP 3 HVY DUTY CAP T CHAIR P T 451-600 LBS Y

12




Matrix Service Category Code Definition SC PA


Durable Medica l Equipmen t (DME) K0854 PWR W C G RP 3 XT RA HVY DTY SLN G SEA T P T 601 LB S OR GRT Y Durable Medica l Equipmen t (DME) K0855 PWR W C G RP 3 X HVY DTY CHR P T W T CA P 601 LB OR GRT Y Durable Medica l Equipmen t (DME) K0856 PWR W C G RP 3 STD 1 PWR SLIN G SEA T P T T O AND EQ 300 LB Y

Durable Medica l Equipmen t (DME) K0857 PWR W C G RP 3 STD 1 PWR CAP T CHAIR P T T O AND EQ 300 LB Y

Durable Medica l Equipmen t (DME) K0858 PWR W C G RP 3 HD 1 PWR SLIN G SEA T P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0859 PWR W C G RP 3 HD 1 PWR CAP T CHAIR P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0860 PWR W C G RP 3 V HD 1 PWR SLIN G SEA T P T 451-600 LB Y Durable Medica l Equipmen t (DME) K0861 PWR W C G RP 3 STD M X PWR SLN G SEA T P T T O AND EQ 300 LB Y

Durable Medica l Equipmen t (DME) K0862 PWR W C G RP 3 HD M X PWR SLIN G SEA T P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0863 PWR W C G RP 3 V HD M X PWR SLN G SEA T P T 451-600 LB Y Durable Medica l Equipmen t (DME) K0864 PWR W C G RP 3 XTR HD M X PWR SLN G SEA T P T 601 LB OR GRT Y

Durable Medica l Equipmen t (DME) K0868 PWR W C G RP 4 STD SLIN G SEA T P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0869 PWR W C G RP 4 STD CAPTAI N CHAIR P T T O AND EQ 300 LBS Y Durable Medica l Equipmen t (DME) K0870 PWR W C G RP 4 HVY DUTY SLIN G SEA T P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0871 PWR W C G RP 4 V HVY DUTY SLIN G SEA T P T 451-600 LB Y Durable Medica l Equipmen t (DME) K0877 PWR W C G RP 4 STD 1 PWR SLIN G SEA T P T T O AND EQ 300 LB Y

Durable Medica l Equipmen t (DME) K0878 PWR W C G RP 4 STD 1 PWR CAP T CHAIR P T T O AND EQ 300 LB Y

Durable Medica l Equipmen t (DME) K0879 PWR W C G RP 4 HD 1 PWR SLIN G SEA T P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0880 PWR W C G RP 4 V HD 1 PWR SLIN G SEA T P T 451-600 LB Y Durable Medica l Equipmen t (DME) K0884 PWR W C G RP 4 STD M X PWR SLN G SEA T P T T O AND EQ 300 LB Y

Durable Medica l Equipmen t (DME) K0885 PWR W C G RP 4 STD M X PWR CAP T CHR P T T O AND EQ 300 LB S Y

Durable Medica l Equipmen t (DME) K0886 PWR W C G RP 4 HD M X PWR SLIN G SEA T P T 301-450 LBS Y Durable Medica l Equipmen t (DME) K0890 PWR W C G RP 5 PED 1 PWR SLIN G SEA T P T T O AND EQ 125 LB Y

Durable Medica l Equipmen t (DME) K0891 PWR W C G RP 5 PED M X PWR SLN G SEA T P T T O AND EQ 125 LB Y

Durable Medica l Equipmen t (DME) K0900 CUSTOMIZED DME OTHER THA N WHEELCHAIR Y Durable Medica l Equipmen t (DME) K1001 Electronic positiona l obstructive slee p apne a treatment , with

sensor , includes al l components an d accessorie s, an y type Y

Durable Medica l Equipmen t (DME) K1002 Crania l electrotherap y stimulatio n (CES ) system , includes all supplies an d accessories , an y type

Y

Durable Medica l Equipmen t (DME) K1003 Whirlpoo l tub , wal k in , portable Y Durable Medica l Equipmen t (DME) K1004 Lo w frequen cy ultrasoni c diatherm y treatmen t device fo r home

use , includes al l components an d accessories Y

Durable Medica l Equipmen t (DME) L8619 Cochlea r implant , externa l spee ch processo r an d controller , integrate d system , replacement

Y Y

Durable Medica l Equipmen t (DME) Q0480 Drive r pneumati c vad , rep Y Durable Medica l Equipmen t (DME) Q4183 SURGIGRAF T PER SQ CM Y Durable Medica l Equipmen t (DME) Q4184 CELLEST A PER SQ CM Y Durable Medica l Equipmen t (DME) Q4185 CELLEST A FLOWABLE AMNION ; PER 0.5 C C Y Durable Medica l Equipmen t (DME) Q4186 EPIFI X PER SQ C M Y Durable Medica l Equipmen t (DME) Q4187 EPICORD PER SQ C M Y Durable Medica l Equipmen t (DME) Q4188 AMNIOARMOR PER SQ CM Y Durable Medica l Equipmen t (DME) Q4190 ARTACEN T A C PER SQ C M Y Durable Medica l Equipmen t (DME) Q4191 RESTORIGI N PER SQ CM Y Durable Medica l Equipmen t (DME) Q4193 COLL-E-DE RM PER SQ CM Y Durable Medica l Equipmen t (DME) Q4194 NOVACHOR PER SQ CM Y Durable Medica l Equipmen t (DME) Q4198 GENESI S AMNIOTI C MEMBRANE PER SQ CM Y Durable Medica l Equipmen t (DME) Q4200 SKINTE PER SQ CM Y Durable Medica l Equipmen t (DME) Q4201 MATRIO N PER SQ CM Y Durable Medica l Equipmen t (DME) Q4202 KEROX X (2.5 G CC ) 1CC Y Durable Medica l Equipmen t (DME) Q4203 DERMA-GIDE PER SQ CM Y Durable Medica l Equipmen t (DME) Q4204 XWRA P PER SQ C M Y Durable Medica l Equipmen t (DME) S1034 ARTI F PANCREA S DEV C SY S THA T CMNC T W AL L DEVC Y Durable Medica l Equipmen t (DME) S1035 SENSO R; INVAS V DSPB L USE ARTI F PANCREA S DEV C SYS Y Durable Medica l Equipmen t (DME) S1036 TRANSMITTE R; EX T USE W ARTI F PANCREA S DEV C SY S Y

13






Durable Medica l Equipmen t (DME) S1037 RECEIVE R; EXTERNA L USE W ARTI F PANCREA S DEV C SYS Y Durable Medica l Equipmen t (DME) T5001 Positionin g sea t fo r persons wit h specia l orthopedi c needs Y Y Durable Medica l Equipmen t (DME) V2530 CONTAC T LEN S SCLERA L GA S IMPERMEABLE PER LEN S Y Durable Medica l Equipmen t (DME) V2531 CONTAC T LEN S SCLERA L GA S PERMEABLE PER LENS Y

Experimental/Investigational 33440 RPLCM T AORTI C VALVE BY TLC J AUTO L PUL M VALVE Y Experimental/Investigational 34718 Endovascula r repai r o f iliac artery , no t associate d wit h placemen t o f Y Experimental/Investigational 46948 Hemorrhoidectomy , internal , b y transana l hemorrhoidal Y Experimental/Investigational 82016 ACYLCARNITINE S QUALITATIVE EACH SPECIME N Y

Experimental/Investigational 82017 ACYLCARNITINE S QUANTIATIVE EACH SPECIMEN Y

Experimental/Investigational 83987 PH EXHALED BREATH CONDENSATE Y

Experimental/Investigational 84145 PROCALCITONI N (PCT ) Y

Experimental/Investigational 86316 IMMUNOASSAY TUMOR ANTIGE N QUANTITATIVE Y

Experimental/Investigational 86343 LEUKOCYTE HISTAMINE RELEASE TES T LHR Y

Experimental/Investigational 93264 REMOTE MNTR WIRELESS P-A RT PRS SNR U P TO 30 D Y

Experimental/Investigational 95803 ACTIGRAPHY TESTING RECORDING ANALYSIS I AND R Y Home Slee p Studies (POS 12) Do Not Require PA

Experimental/Investigational 95836 ECOG IMPLANTED BRAIN NPGT W REC I AND R UNDER 30 DAYS Y

Experimental/Investigational

95976 ELE C ALY S IMPL T SMP L C N NPG T PRGRMG

Y Experimental/Investigational 95977 ELE C ALY S IMPL T CPL X C N NPG T PRGRM G Y Experimental/Investigational 95983 ELE C ALY S IMPL T B RN NPG T PRGRM G 1S T 15 MIN Y

Experimental/Investigational 0054T CPTR-ASS T MUSCSKE L NAVIG J ORTH O FLUOR IMAGES Y

Experimental/Investigational 0055T CPTR-ASS T MUSCSKE L NAVIG J ORTH O C T MRI Y

Experimental/Investigational 0058T CRYOPRESERVATIO N REPRODUCTIVE TISSUE OVARIAN Y

14






Experimental/Investigational 0071T U S ABLAT J UTERINE LEIOMYOMAT A UNDER 200 C C TISSUE Y

Experimental/Investigational 0072T US ABLAT J UTERINE LEIOMYOMA T OR MOREEQUA L 200 C C TISS Y

Experimental/Investigational 0075T TCA T PLM T XTRC V RT CRTD STEN T RS AND I PRQ 1S T VS L Y

Experimental/Investigational 0085T BREATH TES T HEA RT TRANSPLAN T REJECTIO N Y

Experimental/Investigational 0100T PLM T SCJNC L RT A PROSTH AND PLS AND IMPLTJ INTRA-OC RT A Y

Experimental/Investigational 0101T EXTRCORPL SHOCK WAVE MUSCSKELE NOS HIGH ENERGY Y

Experimental/Investigational 0102T EXTRCRPL SHOCK WAVE W ANES LAT HUMERL EPICONDYLE Y

Experimental/Investigational 0106T QUANT SENSORY TEST AND INTERPJ XTR W TOUCH STIMULI Y

Experimental/Investigational 0107T QUANT SENSORY TEST AND INTERPJ XTR W VIBRJ STIMULI Y

Experimental/Investigational 0108T QUAN T SENSORY TES T AND INTERP J XTR W COO L STIMULI Y Experimental/Investigational 0109T QUAN T SENAORY TES T AND INTERP J XTR W HT-P N STIMULI Y Experimental/Investigational 0110T QUAN T SENSORY TES T AND INTERP J XTR OTHER STIMULI Y Experimental/Investigational 0111T LONG-CHAI N OMEGA-3 FATTY ACID S RB C MEMBS Y

Experimental/Investigational 0126T COMMO N CAROTID INTIM A MEDI A THICKNES S STUDY Y Experimental/Investigational 0184T RECTA L TUMOR EXCISIO N TRANSANA L ENDOSCOPIC Y

Experimental/Investigational 0191T AN T SEGMEN T INSERTIO N DRAINAGE W O RESERVOIR INT Y Experimental/Investigational 0198T MEA S OCULAR BLOOD FLOW REPEA T I O PRE S SAM P W I AND R Y Experimental/Investigational 0200T PERQ SA C AGMNT J UNI W W O BAL O MCHN L DE V 1 OR G RT NDL Y

Experimental/Investigational 0201T PERQ SA C AGMNT J BI W W O BAL O MCHN L DE V 2 OR G RT NDL S Y Experimental/Investigational 0202T POS T VE RT ARTHRPLSTY W W O BONE CEMEN T 1 LUMB LV L Y Experimental/Investigational 0203U AI IBD MRN A XPRS N PRF L 17 Y Experimental/Investigational 0204U ON C THYR MRN A XPRS N ALY S 593 Y Experimental/Investigational 0205U OPH AMD ALY S 3 GENE VARIANTS Y Experimental/Investigational 0206U NEU RO ALZHEIMER CEL L AGGREGJ Y Experimental/Investigational 0207T EVA C MEIBOMIA N GLND S AUT O H T AND INTM T PRES S UNI Y Experimental/Investigational 0207U NEU RO ALZHEIMER QUA N IMAGING Y Experimental/Investigational 0208T PURE TONE AUDIOMETRY AUTOMATED AIR ONLY Y

15



Experimental/Investigational 0208U ONC MTC MRNA XPRSN ALYS 108 Y Experimental/Investigational 0209T PURE TONE AUDIOMETRY AUTOMATED AIR AND BONE Y Experimental/Investigational 0209U CYTOG CONST ALYS INTERROG Y

Experimental/Investigational 0210T SPEECH AUDIOMETRY THRESHOLD AUTOMATED Y Experimental/Investigational 0210U SYPHILIS TST ANTB IA QUAN Y Experimental/Investigational 0211T SPEECH AUDIOM THRESHLD AUTO W SPEECH RECOGNITION Y Experimental/Investigational 0211U ONC PAN-TUM DNA&RNA GNRJ SEQ Y Experimental/Investigational 0212T COMPRE AUDIOM THRESHOLD EVAL AND SPEECH RECOG Y Experimental/Investigational 0212U RARE DS GEN DNA ALYS PROBAND Y Experimental/Investigational 0213T NJX DX THER PARAVER FCT JT W US CER THOR 1 LVL Y Experimental/Investigational 0213U RARE DS GEN DNA ALYS EA COMP Y Experimental/Investigational 0214T NJX DX THER PARAVER FCT JT W US CER THOR 2ND LVL Y Experimental/Investigational 0214U RARE DS XOM DNA ALYS PROBAND Y Experimental/Investigational 0215T NJX PARAVERTBRL FACET JT W US CER THOR 3RD AND OVER LVL Y Experimental/Investigational 0215U RARE DS XOM DNA ALYS EA COMP Y Experimental/Investigational 0216T NJX DX THER PARAVER FCT JT W US LUMB SAC 1 LVL Y Experimental/Investigational 0216U NEURO INH ATAXIA DNA 12 COM Y Experimental/Investigational 0217T NJX DX THER PARAVER FCT JT W US LUMB SAC LVL 2 Y

Experimental/Investigational 0217U NEURO INH ATAXIA DNA 51 GENE Y

Experimental/Investigational 0218T NJX PARAVERTBRL FCT JT W US LUMB SAC 3RD AND OVER LVL Y Experimental/Investigational 0218U NEURO MUSC DYS DMD SEQ ALYS Y

Experimental/Investigational 0219T PLMT POST FACET IMPLANT UNI BI W IMG AND GRFT CERV Y Experimental/Investigational 0219U NFCT AGT HIV GNRJ SEQ ALYS Y Experimental/Investigational 0220T PLMT POST FACET IMPLT UNI BI W IMG AND GRFT THOR Y Experimental/Investigational 0220U ONC BRST CA AI ASSMT 12 FEAT Y Experimental/Investigational 0221T PLMT POST FACET IMPLT UNI BI W IMG AND GRFT LUMB Y Experimental/Investigational 0221U ABO GNOTYP NEXT GNRJ SEQ ABO Y Experimental/Investigational 0222U RHD&RHCE GNTYP NEXT GNRJ SEQ Y Experimental/Investigational 0228T NJX ANES STEROID TFRML EDRL W US CER THOR 1 LVL Y Experimental/Investigational 0229T NJX ANES STERD TFRML EDRL W US CER THOR EA ADDL Y Experimental/Investigational 0230T NJX ANES STEROID TFRML EDRL W US LUM SAC 1 LVL Y Experimental/Investigational 0231T NJX ANES STEROID TFRML EDRL W US LUM SAC EA ADDL Y Experimental/Investigational 0234T TRLUML PERIPHERAL ATHERECTOMY RENAL ARTERY EA Y Experimental/Investigational 0235T TRLUML PERIPHERAL ATHERECTOMY VISCERAL ARTERY EA Y Experimental/Investigational 0236T Transluminal peripheral atherectomy, open or percutaneous, Y Experimental/Investigational 0237T Transluminal peripheral atherectomy, open or percutaneous,

including radiological supervision and interpretation; Y

Experimental/Investigational 0238T Transluminal peripheral atherectomy, open or percutaneous, Y Experimental/Investigational 0253T INSERT ANT SGM DRAINAGE DEV W O RESERVR INT APPR Y Experimental/Investigational 0263T AUTO BONE MARRW CELL RX COMPLT BONE MARRW HARVST Y

Experimental/Investigational 0264T AUTO BONE MARRW CELL RX COMP W O BONE MAR HARVST Y Experimental/Investigational 0265T BONE MAR HARVST ONLY FOR INTMUSC AUTOLO CELL RX Y Experimental/Investigational 0266T IM REPL CARTD SINUS BAROREFLX ACTIV DEV TOT SYST Y Experimental/Investigational 0267T IM REPL CARTD SINS BAROREFLX ACTIV DEV LEAD ONLY Y Experimental/Investigational 0268T IM REPL CARTD SINS BARREFLX ACT DEV PLS GEN ONLY Y Experimental/Investigational 0269T REV REMVL CARTD SINS BARREFLX ACT DEV TOT SYSTEM Y Experimental/Investigational 0270T REV REMVL CARTD SINS BARREFLX ACT DEV LEAD ONLY Y Experimental/Investigational 0271T REV REM CARTD SINS BARREFLX ACT DEV PLS GEN ONLY Y Experimental/Investigational 0272T INTRGORTION DEV EVAL CARTD SINS BARREFLX W I AND R Y Experimental/Investigational 0273T INTROGATION DEV EVAL CARTD SINS BARREFLX W PRGRM Y

Experimental/Investigational 0274T PERC LAMINO- LAMINECTOMY IMAGE GUIDE CERV THORAC Y




Molina Healthcare of South Carolina, In





Experimental/Investigational 0275T PE RC LAMINO- LAMINECTOMY INDIR IMA G GUIDE LUMBAR Y

Experimental/Investigational 0278T TRNSCU T ELEC T MODLATIO N PAI N REPROCE S E A T X SES S Y �Experimental/Investigational 0295 T EX T EC G OVER 48HR T O 21 DAY RCRD SCA N ANLY S RE P R AND I Y

Experimental/Investigational 0296T EXT ECG OVER 48HR TO 21 DAY RCRD W CONECT INTL RCRD Y Experimental/Investigational 0297T EXT ECG OVER 48HR TO 21 DAY SCAN ANALYSIS W REPORT Y Experimental/Investigational 0298T EXT ECG OVER 48HR TO 21 DAY REVIEW AND INTERPRETATN Y Experimental/Investigational 0312T LAPS IMPLTJ NSTIM ELTRD ARRAY AND PLS GEN VAGUS NRV Y Experimental/Investigational 0313T LAPS REVJ REPLCMT NSTIM ELTRD ARRAY VAGUS NRV Y Experimental/Investigational 0314T LAPS RMVL NSTIM ELTRD ARRAY AND PLS GEN VAGUS NRV Y Experimental/Investigational 0315T REMOVAL PULSE GENERATOR VAGUS NERVE Y Experimental/Investigational 0316T REPLACEMENT PULSE GENERATOR VAGUS NERVE Y Experimental/Investigational 0317T ELEC ALYS NSTIM PLS GEN VAGUS NRV W REPRGRMG Y Experimental/Investigational 0329T MNTR INTRAOCULAR PRESS 24HRS OR GRT UNI BI W INTERP Y Experimental/Investigational 0330T TEAR FILM IMAGING UNILATERAL OR BILATERAL W I AND R Y Experimental/Investigational 0333T VISUAL EVOKED POTENTIAL ACUITY SCREENING AUTO Y Experimental/Investigational 0335T INSERTION OF SINUS TARSI IMPLANT Y Experimental/Investigational 0338T TRANSCATHETER RENAL SYMPATH DENERVATION UNILAT Y Experimental/Investigational 0339T TRANSCATHETER RENAL SYMPATH DENERVATION BILAT Y

Experimental/Investigational 0342T THERAPEUTIC APHERESIS W SELECTIVE HDL DELIP Y Experimental/Investigational 0347T PLACE INTERSTITIAL DEVICE(S) IN BONE FOR RSA Y Experimental/Investigational 0348T RADIOSTEREOMETRIC ANALYSIS SPINE EXAM Y Experimental/Investigational 0349T RADIOSTEREOMETRIC ANALYSIS UPPER EXTREMITY EXAM Y Experimental/Investigational 0350T RADIOSTEREOMETRIC ANALYSIS LOWER EXTREMITY EXAM Y Experimental/Investigational 0351T INTRAOP OCT BREAST OR AXILL NODE EACH SPECIMEN Y Experimental/Investigational 0352T OCT BREAST OR AXILL NODE SPECIMEN I AND R Y Experimental/Investigational 0353T OCT OF BREAST SURG CAVITY REAL TIME INTRAOP Y Experimental/Investigational 0354T OCT BREAST SURG CAVITY REAL TIME REFERRED I AND R Y Experimental/Investigational 0355T GI TRACT IMAGING INTRALUMINAL COLON WITH I AND R Y Experimental/Investigational 0356T INSERT DRUG IMPLANT INTO LACRIMAL CANAL FOR IOP Y Experimental/Investigational 0358T BIA WHOLE BODY COMPOSITION ASSESSMENT W I AND R Y Experimental/Investigational 0394T HDR ELECTRONIC BRACHYTHERAPY SKIN SURFACE Y Experimental/Investigational 0395T HDR ELECTRONIC BRACHYTHERAPY NTRSTL INTRCAV Y Experimental/Investigational 0396T INTRAOP KINETIC BALANCE SENSR KNEE RPLCMT ARTHRP Y Experimental/Investigational 0397T ERCP WITH OPTICAL ENDOMICROSCOPY ADD ON Y Experimental/Investigational 0398T MRGFUS STEREOTACTIC ABLATION LESION INTRACRANIAL Y Experimental/Investigational 0400T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 1-5 LES Y Experimental/Investigational 0401T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 6 PLUS LES Y Experimental/Investigational 0402T COLLAGEN CROSS-LINKING OF CORNEA MED SEPARATE Y Experimental/Investigational 0403T DIABETES PREVENTION PROG STANDARDIZED CURRICULUM Y Experimental/Investigational 0404T TRANSCERVICAL UTERINE FIBROID ABLTJ W US GDN RF Y Experimental/Investigational 0405T OVERSIGHT CARE OF XTRCORP LIVER ASSIST SYS PAT Y Experimental/Investigational 0408T INSJ RPLC CAR MODULJ SYS PLS GEN TRANSVNS ELTRD Y Experimental/Investigational 0409T INSJ RPLC CARDIAC MODULJ SYS PLS GENERATOR ONLY Y Experimental/Investigational 0410T INSJ RPLC CARDIAC MODULJ SYS ATR ELECTRODE ONLY Y Experimental/Investigational 0411T INSJ RPLC CAR MODULJ SYS VENTR ELECTRODE ONLY Y Experimental/Investigational 0412T REMOVAL CARDIAC MODULJ SYS PLS GENERATOR ONLY Y Experimental/Investigational 0413T REMOVAL CARDIAC MODULJ SYS TRANSVENOUS ELECTRODE Y Experimental/Investigational 0414T RMVL AND RPL CARDIAC MODULJ SYS PLS GENERATOR ONLY Y Experimental/Investigational 0415T REPOS CARDIAC MODULJ SYS TRANSVENOUS ELECTRODE Y Experimental/Investigational 0416T RELOC SKIN POCKET CARDIAC MODULJ PULSE GENERATOR Y Experimental/Investigational 0417T PRGRMG DEVICE EVALUATION CARDIAC MODULJ SYSTEM Y

c.

17



Experimental/Investigational 0418T INTERRO DEVICE EVALUATION CARDIAC MODULJ SYSTEM Y Experimental/Investigational 0419T DSTRJ NEUROFIBROMAS XTNSV FACE HEAD NECK OVER 50 Y Experimental/Investigational 0420T DSTRJ NEUROFIBROMAS XTNSV TRNK EXTREMITIES OVER 100 Y Experimental/Investigational 0421T TRANSURETHRAL WATERJET ABLATION PROSTATE COMPL Y Experimental/Investigational 0422T TACTILE BREAST IMG COMPUTER-AIDED SENSORS UNI BI Y Experimental/Investigational 0423T SECRETORY TYPE II PHOSPHOLIPASE A2 (SPLA2-IIA) Y Experimental/Investigational 0424T INSJ RPLC NSTIM SYSTEM SLEEP APNEA COMPLETE Y Experimental/Investigational 0425T INSJ RPLC NSTIM SYSTEM SLEEP APNEA SENSING LEAD Y Experimental/Investigational 0426T INSJ RPLC NSTIM SYSTEM SLEEP APNEA STIMJ LEAD Y Experimental/Investigational 0427T INSJ RPLC NSTIM SYSTEM SLEEP APNEA PLS GENERATOR Y Experimental/Investigational 0428T REMOVAL NSTIM SYSTEM SLEEP APNEA PLS GENERATOR Y Experimental/Investigational 0429T REMOVAL NSTIM SYSTEM SLEEP APNEA SENSING LEAD Y Experimental/Investigational 0430T REMOVAL NSTIM SYSTEM SLEEP APNEA STIMJ LEAD Y Experimental/Investigational 0431T RMVL RPLC NSTIM SYSTEM SLEEP APNEA PLS GENERATOR Y Experimental/Investigational 0432T REPOS NSTIM SYSTEM SLEEP APNEA STIMJ LEAD Y Experimental/Investigational 0433T REPOS NSTIM SYSTEM SLEEP APNEA SENSING LEAD Y Experimental/Investigational 0434T INTERRO DEV EVAL NSTIM PLS GEN SYS SLEEP APNEA Y Experimental/Investigational 0435T PRGRMG EVAL NSTIM PLS GEN SYS SLEEP APNEA 1 SESS Y Experimental/Investigational 0436T PRGRMG EVAL NSTIM PLS GEN SYS SLEEP APNEA STUDY Y Experimental/Investigational 0437T IMPLTJ NONBIOL SYNTH IMPLT FASC RNFCMT ABDL WALL Y Experimental/Investigational 0440T ABLTJ PERC CRYOABLTJ IMG GDN UXTR PERPH NERVE Y Experimental/Investigational 0441T ABLTJ PERC CRYOABLTJ IMG GDN LXTR PERPH NERVE Y Experimental/Investigational 0442T ABLTJ PERC CRYOABLTJ IMG GDN NRV PLEX TRNCL NRV Y Experimental/Investigational 0443T R-T SPCTRL ALYS PRST8 TISS FLUORESCENC SPCTRSCPY Y Experimental/Investigational 0444T INITIAL PLMT DRUG ELUTING OCULAR INSERT UNI BI Y Experimental/Investigational 0445T SBSQ PLMT DRUG ELUTING OCULAR INSERT UNI BI Y Experimental/Investigational 0446T CRTJ SUBQ INSJ IMPLTBL GLUCOSE SENSOR SYS TRAIN Y Experimental/Investigational 0447T RMVL IMPLTBL GLUCOSE SENSOR SUBQ POCKET VIA INC Y Experimental/Investigational 0448T RMVL INSJ IMPLTBL GLUC SENSOR DIF ANATOMIC SITE Y Experimental/Investigational 0469T RTA POLARIZE SCAN OC SCR W ONSITE AUTO RSLT BI Y Experimental/Investigational 0470T OCT SKN IMG ACQUISJ I AND R 1ST LES Y Experimental/Investigational 0472T DEV INTERR PRGRMG IO RTA ELTRD RA W ADJ AND REPRT Y Experimental/Investigational 0473T DEV INTERR REPRGRMG IO RTA ELTRD RA W REPRT Y Experimental/Investigational 0474T INSJ ANT SEG AQUEOUS DRG DEV W IO RSVR Y Experimental/Investigational 0475T REC FTL CAR SGL 3 CH PT REC AND STRG DATA SCN I AND R Y Experimental/Investigational 0476T REC FTL CAR SGL PT REC SCAN W RAW ELEC TR DATA Y Experimental/Investigational 0477T REC FTL CAR SGL 3 CH SGL XTRJ TECHL ALYS Y Experimental/Investigational 0478T REC FTL CAR SGL 3 CH REVIEW I AND R Y Experimental/Investigational 0479T FRACTIONAL ABL LSR FENESTRATION FIRST 100 SQCM Y Experimental/Investigational 0481T NJX AUTOL WBC CONCENTR INC IMG GDN HRV AND PREP Y Experimental/Investigational 0483T TMVI W PROSTHETIC VALVE PERCUTANEOUS APPROACH Y Experimental/Investigational 0484T TMVI W PROSTHETIC VALVE TRANSTHORACIC EXPOSURE Y Experimental/Investigational 0485T OCT MIDDLE EAR WITH I AND R UNILATERAL Y Experimental/Investigational 0486T OCT MIDDLE EAR WITH I AND R BILATERAL Y Experimental/Investigational 0487T TRANSVAGINAL BIOMECHANICAL MAPPING W REPORT Y Experimental/Investigational 0488T DIABETES PREV ONLINE ELECTRONIC PRGRM PR 30 DAYS Y Experimental/Investigational 0489T AUTOL REGN CELL TX SCLERODERMA HANDS Y Experimental/Investigational 0490T AUTOL REGN CELL TX SCLDR MLT INJ 1 OR GRT HANDS Y Experimental/Investigational 0491T ABL LASER TX OPEN WND PR DAY 1ST 20 SQCM OR LESS Y Experimental/Investigational 0493T NEAR INFRARED SPECTROSCPY STUDIES LOW EXT WOUNDS Y Experimental/Investigational 0494T PREP AND CANNULJ CDVR DON LNG ORGN PRFUJ SYS Y Experimental/Investigational 0495T INIT AND MNTR CDVR DON LNG ORGN PRFUJ SYS 1ST 2 HR Y Experimental/Investigational 0497T XTRNL PT ACT ECG W O ATTN MNTR IN-OFFICE CONN Y Experimental/Investigational 0498T XTRNL PT ACT ECG W O ATTN MNTR R AND I PR 30 DAYS Y Experimental/Investigational 0499T CYSTO W DIL AND URTL RX DEL F URTL STRIX STENOSIS Y Experimental/Investigational 0500T IADNA HPV 5 PLUS SEP REPRT HIGH RISK HPV TYPES Y Experimental/Investigational 0505T EV FEMPOP ARTL REVSC TCAT PLMT IV ST GRF AND CLSR Y Experimental/Investigational 0506T MAC PGMT OPTICAL DNS MEAS HFP UNI BI W I AND R Y Experimental/Investigational 0507T NEAR INFRARED DUAL IMG MEIBOMIAN GLND UNI BI I AND R Y Experimental/Investigational 0508T PLS ECHO US B1 DNS MEAS INDIC AXL B1 MIN DNS TIB Y Experimental/Investigational 0509T PATTERN ELECTRORETINOGRAPHY W I AND R Y Experimental/Investigational 0510T REMOVAL OF SINUS TARSI IMPLANT Y Experimental/Investigational 0511T REMOVAL AND REINSERTION OF SINUS TARSI IMPLANT Y Experimental/Investigational 0512T ESW INTEGUMENTARY WOUND HEALING INITIAL WOUND Y Experimental/Investigational 0514T INTRAOPERATIVE VISUAL AXIS ID USING PT FIXATION Y




ed neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters






Experimental/Investigational 0515T INSERTION WRLS CAR STIMULATOR LV PACG COMPL SYS Y Experimental/Investigational 0516T INSERTION WRLS CAR STIMULATOR LV PACG ELTRD ONLY Y Experimental/Investigational 0517T INSERTION WRLS CAR STIMULATOR LV PACG PG COMPNT Y Experimental/Investigational 0518T REMOVAL PG COMPNT ONLY WRLS CAR STIMULATOR Y Experimental/Investigational 0519T REMOVAL AND RPLCMT WRLS CAR STIMULATOR PG COMPNT Y Experimental/Investigational 0520T REMOVAL AND RPLCMT WRLS CAR STIMULATOR W NEW ELTRD Y Experimental/Investigational 0521T INTERROG DEV EVAL WRLS CAR STIMULATOR IN PERSON Y Experimental/Investigational 0522T PRGRMG DEVICE EVAL WRLS CAR STIMULATOR IN PERSON Y Experimental/Investigational 0523T INTRAPROCEDURAL CORONARY FFP W 3D FUNCJL MAPPING Y Experimental/Investigational 0524T EV CATHETER DIR CHEM ABLTJ INCMPTNT XTR VEIN Y Experimental/Investigational 0525T INSERTION REPLACEMENT COMPLETE IIMS Y Experimental/Investigational 0526T INSERTION REPLACEMENT IIMS ELECTRODE ONLY Y Experimental/Investigational 0527T INSERTION REPLACEMENT IIMS IMPLANTABLE MNTR ONLY Y Experimental/Investigational 0528T PRGRMG DEVICE EVAL IIMS IN PERSON Y Experimental/Investigational 0529T INTERROGATION DEVICE EVAL IIMS IN PERSON Y Experimental/Investigational 0530T REMOVAL COMPLETE IIMS INCL IMG S AND I Y Experimental/Investigational 0531T REMOVAL IIMS ELECTRODE ONLY INCL IMG S AND I Y Experimental/Investigational 0532T REMOVAL IIMS IMPLANTABLE MNTR ONLY INCL IMG S AND I Y Experimental/Investigational 0533T CONTINUOUS REC MVMT DO SX 6 D UNDER 10 D Y Experimental/Investigational 0534T CONT REC MVMT DO SX 6 D UNDER 10 D SETUP AND PT TRAINJ Y Experimental/Investigational 0535T CONT REC MVMT DO SX 6 D UNDER 10 D 1ST REPRT CNFIG Y

Experimental/Investigational 0536T CONT REC MVMT DO SX 6 D UNDER 10 D DL REVIEW I AND R Y Experimental/Investigational 0541T MYOCARDIAL IMG BY MCG DETCJ CARDIAC ISCHEMIA Y Experimental/Investigational 0542T MYOCARDIAL IMG BY MCG DETCJ CARDIAC ISCHEMIA I AND R Y Experimental/Investigational 0563T Evacuation of meibomian glands, using heat delivered through Y Experimental/Investigational 0564T Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem Y Experimental/Investigational 0565T Autologous cellular implant derived from adipose tissue for the Y Experimental/Investigational 0566T Autologous cellular implant derived from adipose tissue for the Y Experimental/Investigational 0567T Permanent fallopian tube occlusion with degradable biopolymer Y Experimental/Investigational 0568T Introduction of mixture of saline and air for sonosalpingography to Y Experimental/Investigational 0569T Transcatheter tricuspid valve repair, percutaneous approach; initial Y Experimental/Investigational 0570T Transcatheter tricuspid valve repair, percutaneous approach; each Y Experimental/Investigational 0571T Insertion or replacement of implantable cardioverter-defibrillator Y Experimental/Investigational 0572T Insertion of substernal implantable defibrillator electrode Y Experimental/Investigational 0573T Removal of substernal implantable defibrillator electrode Y

Experimental/Investigational 0574T Repositioning of previously implanted substernal implantable Y Experimental/Investigational 0575T Programming device evaluation (in person) of implantable Y Experimental/Investigational 0576T Interrogation device evaluation (in person) of implantable Y Experimental/Investigational 0577T Electrophysiological evaluation of implantable cardioverter- Y Experimental/Investigational 0578T Interrogation device evaluation(s) (remote), up to 90 days, Y Experimental/Investigational 0579T Interrogation device evaluation(s) (remote), up to 90 days, Y Experimental/Investigational 0580T Removal of substernal implantable defibrillator pulse generator Y Experimental/Investigational 0581T Ablation, malignant breast tumor(s), percutaneous, cryotherapy, Y Experimental/Investigational 0582T Transurethral ablation of malignant prostate tissue by high-energy Y Experimental/Investigational 0583T Tympanostomy (requiring insertion of ventilating tube), using an Y Experimental/Investigational 0587T Percutaneous implantation or replacement of integrated single Y Experimental/Investigational 0588T Revision or removal of integrated single device neurostimulation Y Experimental/Investigational 0589T Electronic analysis with simple programming of implanted

integrated neurostimulation system (eg, electrode array and Y

Experimental/Investigational 0590T Electronic analysis with complex programming of implanted integrat Y Experimental/Investigational 0594T Osteotomy, humerus, with insertion of an externally controlled Y Experimental/Investigational 0596T Temporary female intraurethral valve-pump (i.e., voiding Y Experimental/Investigational 0597T Temporary female intraurethral valve-pump (i.e., voiding Y Experimental/Investigational 0598T Noncontact real-time fluorescence wound imaging, for bacterial

presence, location, and load, per session; first anatomic site (e.g., Y

Experimental/Investigational 0599T Noncontact real-time fluorescence wound imaging, for bacterial Y Experimental/Investigational 0600T Ablation, irreversible electroporation; 1 or more tumors per organ, Y Experimental/Investigational 0601T Ablation, irreversible electroporation; 1 or more tumors, including Y Experimental/Investigational 0602T Glomerular filtration rate (GFR) measurement(s), transdermal, Y Experimental/Investigational 0603T Glomerular filtration rate (GFR) monitoring, transdermal, including Y Experimental/Investigational 0604T Optical coherence tomography (OCT) of retina, remote, patient- Y Experimental/Investigational 0605T Optical coherence tomography (OCT) of retina, remote, patient- Y Experimental/Investigational 0606T Optical coherence tomography (OCT) of retina, remote, patient- Y

19



Experimental/Investigational 0607T Remote monitoring of an external continuous pulmonary fluid Y Experimental/Investigational 0608T Remote monitoring of an external continuous pulmonary fluid Y Experimental/Investigational 0609T Magnetic resonance spectroscopy, determination and localization Y Experimental/Investigational 0610T Magnetic resonance spectroscopy, determination and localization Y Experimental/Investigational 0611T Magnetic resonance spectroscopy, determination and localization Y Experimental/Investigational 0612T Magnetic resonance spectroscopy, determination and localization Y Experimental/Investigational 0613T Percutaneous transcatheter implantation of interatrial septal shunt Y Experimental/Investigational 0614T Removal and replacement of substernal implantable defibrillator

pulse generator Y

Experimental/Investigational 0615T Eye-movement analysis without spatial calibration, with interpretation and report

Y

Experimental/Investigational 0616T Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline

Y

Experimental/Investigational 0617T Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with removal of crystalline lens and insertion of intraocular lens

Y

Experimental/Investigational 0618T Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with secondary intraocular lens placement or intraocular lens exchange

Y

Experimental/Investigational 0619T Cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed

Y

Experimental/Investigational A4563 RECTAL CNTRL SYS VAG INSRT LT USE ANY TYPE EA Y

Experimental/Investigational C1823 GENERATR NEUROSTIM NON-RECHRGABL TV S AND STIM LEADS Y

Experimental/Investigational C1824 Generator, cardiac contractility modulation (implantable) Y

Experimental/Investigational C2596 Probe, image guided, robotic, waterjet ablation Y

Experimental/Investigational C8937 CMP-AID DETN INCL CMP ALG ANALYS BR MRI IMG DATA Y

Experimental/Investigational C9751 BRONCHOSCOPY RIGID FLEXIBLE TRANSBRON ABL LESION Y

Experimental/Investigational C9752 DESTRUC IO BASIVERTEB NERV 1ST 2 VERT B LUMB SAC Y






Experimental/Investigational C9753 DESTRUC IO BASIVERTEB NERV EA ADD VERT BODY L S Y

Experimental/Investigational C9758 Blinded procedure for NYHA Class III/IV heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, transesophageal echocardiography (TEE)/intracardiac echocardiography (ICE), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an

Y

Experimental/Investigational L8608 MISC EXT COMP SPL ACSS FOR ARGUS II RET PROS SYS Y

Experimental/Investigational Q4161 BIO-CONNEKT WOUND MATRIX PER SQUARE CENTIMETER Y

Experimental/Investigational Q4162 WOUNDEX FLOW BIOSKIN FLOW 0.5 CC Y

Experimental/Investigational Q4163 WOUNDEX BIOSKIN PER SQUARE CM Y

Experimental/Investigational Q4164 HELICOLL PER SQUARE CENTIMETER Y

Experimental/Investigational Q4165 KERAMATRIX PER SQUARE CENTIMETER Y

Experimental/Investigational Q4189 ARTACENT AC 1 MG Y

Experimental/Investigational Q4192 RESTORIGIN 1 CC Y

Experimental/Investigational Q4195 PURAPLY PER SQ CM Y

Experimental/Investigational Q4196 PURAPLY AM PER SQ CM Y

Experimental/Investigational Q4197 PURAPLY XT PER SQ CM Y Genetic Counseling & Testing 80145 Adalimumab Y

Genetic Counseling & Testing 80187 Posaconazole Y

Genetic Counseling & Testing 80230 Infliximab Y






Genetic Counseling & Testing 80235 Lacosamide Y

Genetic Counseling & Testing 80280 Vedolizumab Y

Genetic Counseling & Testing 80285 Voriconazole Y

Genetic Counseling & Testing 80303 MECP2 GENE ANALYSIS KNOWN FAMILIAL VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81105 HPA-1 GENOTYPING GENE ANALYSIS COMMON VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.















Genetic Counseling & Testing 81120 IDH1 COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81121 IDH2 COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81161 DMD DUPLICATION DELETION ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Geneti c Counselin g & Testing 81162 BRCA1 BRCA2 GENE ALYS FULL SEQ FULL DUP DEL ALYS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81163 BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Geneti c Counselin g & Testing 81164 BRCA1 BRCA2 GENE ANALYSIS FULL DUP DEL ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81165 BRCA1 GENE ANALYSIS FULL SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81166 BRCA1 GENE ANALYSIS FULL DUP DEL ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81167 BRCA2 GENE ANALYSIS FULL DUP DEL ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81171 AFF2 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Geneti c Counselin g & Testing 81172 AFF2 GENE ANALYSIS CHARACTERIZATION OF ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counselin g & Testing 81173 AR GENE ANALYSIS FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counselin g & Testing 81174 AR GENE ANALYSIS KNOWN FAMILIAL VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counselin g & Testing 81175 ASXL1 GENE ANALYSIS FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Geneti c Counselin g & Testing 81176 ASXL1 GENE ANALYSIS TARGETED SEQ ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Geneti c Counselin g & Testing 81177 ATN1 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counselin g & Testing 81178 ATXN1 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81179 ATXN2 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.




Geneti c Counselin g & Testing 81180 ATXN3 GENE ANALYSI S EVA L DETEC T ABNORMA L ALLELES Y

Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 81181 ATXN7 GENE ANALYSIS EVA L DETEC T ABNORMA L ALLELES Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 81182 ATXN8OS GENE ANALYSIS EVA L DETEC T ABNOR ALLELES Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 81183 ATXN10 GENE ANALYSIS EVA L DETC ABNORMA L ALLELES Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 81184 CACNA1 A GENE ANALYSIS EVA L DETEC T ABNOR ALLELES Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Geneti c Counselin g & Testing 81185 CACNA1 A GENE ANALYSI S FUL L GENE SEQUENCE Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through Geneti c Counselin g & Testing 81186 CACNA1 A GENE ANALYSI S KNOW N FAMILIA L VARIAN T Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through

amniocentesi s an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 81187 CNB P GENE ANALYSI S EVA L DETEC T ABNORMA L ALLELE S Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesi s an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 81188 CSTB GENE ANALYSI S EVA L DETEC T ABNORMA L ALLELE S Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 81189 CSTB GENE ANALYSIS FUL L GENE SEQUENCE Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 81190 CSTB GENE ANALYSIS KNOW N FAMILIA L VARIANTS Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesi s an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 81201 AP C GENE ANALYSI S FUL L GENE SEQUENCE Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesi s an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 81202 AP C GEN E ANALYSIS KNOW N FAMILIA L VARIANTS Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through Geneti c Counselin g & Testing 81203 AP C GENE ANALYSI S DUPLICATIO N DELETIO N VARIANT S Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through Geneti c Counselin g & Testing 81204 AR GENE ANALYSI S CHARACTERIZATIO N O F ALLELE S Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through Geneti c Counselin g & Testing 81205 BCKDHB GENE ANALYSI S COMMO N VARIANT S Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through Geneti c Counselin g & Testing 81210 BRA F GENE ANALYSI S V600 VARIANT(S ) Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through Geneti c Counselin g & Testing 81212 BRCA1 BRC A 2 GE N ALY S 185DELA G 5385INS C 6174DEL T Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through Geneti c Counselin g & Testing 81215 BRCA1 GENE ANALYSI S KNOW N FAMILIA L VARIAN T Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through

amniocentesi s an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 81216 BRCA2 GENE ANALYSI S FUL L SEQUENCE ANALYSI S Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesi s an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 81217 BRCA2 GENE ANALYSI S KNOW N FAMILIA L VARIAN T Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesi s an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 81218 CEBP A GENE ANALYSI S FUL L GENE SEQUENCE Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 81219 CALR GENE ANALYSI S COMMO N VARIANT S I N EXO N 9 Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 81221 CFTR GENE ANALYSIS KNOW N FAMILIA L VARIANTS Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 81222 CFTR GENE ANALYSIS DUPLICATIO N DELETIO N VARIANTS Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 81223 CFTR GENE ANALYSIS FUL L GENE SEQUENCE Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.









Genetic Counseling & Testing 81225 CYP2C19 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81226 CYP2D6 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81227 CYP2C9 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81228 CYTOGENOM CONST MICROARRAY COPY NUMBER VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81229 CYTOGENOM CONST MICROARRAY COPY NUMBER AND SNP VAR Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81230 CYP3A4 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81231 CYP3A5 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81232 DYPD GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81233 BTK GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81234 DMPK GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81235 EGFR GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81236 EZH2 GENE ANALYSIS FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81237 EZH2 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81238 F9 FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81239 DMPK GENE ANALYSIS CHARACTERIZATION OF ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81243 FMR1 ANALYSIS EVAL TO DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81244 FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81246 FLT3 GENE ANLYS TYROSINE KINASE DOMAIN VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81247 G6PD GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81248 G6PD GENE ANALYSIS KNOWN FAMILIAL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81249 G6PD GENE ANALYSIS FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

25






Genetic Counselin g & Testing 81252 GJB2 GENE ANALYSIS FUL L GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81253 GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81257 HBA1 HBA2 GENE ANALYSIS COMMON DELETIONS VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81258 HBA1 HBA2 GENE ANALYSIS KNOWN FAMILIAL VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81259 HBA1 HBA2 GENE ANALYSIS FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81265 COMPARATIVE ANAL STR MARKERS PATIENT AND COMP SPEC Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81266 COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81269 HBA1 HBA2 GENE ANALYSIS DUP DEL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81271 HTT GENE ANALYSIS DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81272 KIT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81273 KIT GENE ANALYSIS D816 VARIANT(S) Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81274 HTT GENE ANALYSIS CHARACTERIZATION ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81275 KRAS GENE ANALYSIS VARIANTS IN EXON 2 Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81276 KRAS GENE ANALYSIS ADDITIONAL VARIANT(S) Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counselin g & Testing 81277 Cytogenomic neoplasi a (genome-wide ) microarra y analysis , interrogatio n o f genomic region s fo r cop y numbe r an d loss-of-heterozygosit y variants fo r chromosoma l abnormalities

Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 81283 IFNL3 GENE ANALYSIS RS12979860 VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81284 FXN GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81285 FXN GENE ANALYSIS CHARACTERIZATION ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81286 FXN GENE ANALYSIS FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81289 FXN GENE ANALYSIS KNOWN FAMILIAL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81291 MTHFR GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

26



Genetic Counseling & Testing 81292 MLH1 GENE ANALYSIS FULL SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81293 MLH1 GENE ANALYSIS KNOWN FAMILIAL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81294 MLH1 GENE ANALYSIS DUPLICATION DELETION VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81295 MSH2 GENE ANALYSIS FULL SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81296 MSH2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81297 MSH2 GENE ANALYSIS DUPLICATION DELETION VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81298 MSH6 GENE ANALYSIS FULL SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81299 MSH6 GENE ANALYSIS KNOWN FAMILIAL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81300 MSH6 GENE ANALYSIS DUPLICATION DELETION VARIA Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81302 MECP2 GENE ANALYSIS FULL SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81304 MECP2 GENE ANALYSIS DUPLICATION DELETION VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81305 MYD88 GENE ANALYSIS P.LEU265 (L265P) VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81306 NUDT15 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81307 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence

Y

Genetic Counseling & Testing 81308 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant

Y

Genetic Counseling & Testing 81309 PIK3C A (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (eg, colorecta l an d breast cancer) gene analysis, targete d sequence analysis (eg , exons 7 , 9 , 20)

Y

Genetic Counseling & Testing 81311 NRAS GENE ANALYSIS VARIANTS IN EXON 2 AND 3 Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81312 PABPN1 GENE ANALYSIS EVAL DETC ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81313 PCA3 KLK3 PROSTATE SPECIFIC ANTIGEN RATIO Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81314 PDGFRA GENE ANALYS TARGETED SEQUENCE ANALYS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81317 PMS2 GENE ANALYSIS FULL SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.









Geneti c Counselin g & Testing 81318 PMS2 GENE ANALYSIS KNOW N FAMILIA L VARIANTS Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 81319 PMS2 GENE ANALYSIS DUPLICATION DELETION VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81320 PLCG2 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81321 PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81322 PTEN GENE ANALYSIS KNOWN FAMILIAL VARIANT

Genetic Counseling & Testing 81323 PTEN GENE ANALYSIS DUPLICATION DELETION VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81324 PMP22 GENE ANAL DUPLICATION DELETION ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81325 PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81326 PMP22 GENE ANALYSIS KNOWN FAMILIAL VARIANT Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81327 SEPT9 GENE PROMOTER METHYLATION ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81328 SLCO1B1 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81329 SMN1 GENE ANALYSIS DOSAGE DELET ALYS W SMN2 ALYS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81333 TGFBI GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81334 RUNX1 GENE ANALYSIS TARGETED SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81335 TPMT GENE ANALAYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81336 SMN1 GENE ANALYSIS FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81337 SMN1 GENE ANALYSIS KNOWN FAMILIAL SEQ VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81343 PPP2R2B GENE ANALYSIS EVAL DETC ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81344 TBP GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81345 TERT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81346 TYMS GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

28






Genetic Counseling & Testing 81350 UGT1A1 GENE ANALYSIS COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81355 VKORC1 GENE ANALYSIS COMMON VARIANT(S) Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81361 HBB COMMON VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81362 HBB KNOWN FAMILIAL VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81363 HBB DUPLICATION DELETION VARIANTS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81364 HBB FULL GENE SEQUENCE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81400 MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.









Genetic Counseling & Testing 81410 AORTIC DYSFUNCTION DILATION GENOMIC SEQ ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81411 AORTIC DYSFUNCTION DILATION DUP DEL ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81412 ASHKENAZI JEWISH ASSOC DSRDRS GEN SEQ ANAL 9 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81413 CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81414 CAR ION CHNNLPATH DUP DEL GN ALYS PANEL 2 GENES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81415 EXOME SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

29






Geneti c Counselin g & Testing 81416 EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 81417 EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81420 FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS Y CPT codes can be auto approved if Prior Authorization is requested with a pregnancy diagnosis, see diagnosis tab for additional information

Genetic Counseling & Testing 81422 FETAL CHROMOSOMAL MICRODELTJ GENOMIC SEQ ANALYS Y CPT codes can be auto approved if Prior Authorization is requested with a pregnancy diagnosis, see diagnosis tab for additional information

Genetic Counseling & Testing 81425 GENOME SEQUENCE ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81426 GENOME SEQUENCE ANALYSIS EACH COMPARATOR GENOME Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81427 GENOME RE-EVALUATION OF PREC OBTAINED GENOME SEQ Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81430 HEARING LOSS GENOMIC SEQUENCE ANALYSIS 60 GENES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81431 HEARING LOSS DUP DEL ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81432 HEREDITARY BRST CA-RELATED GEN SEQ ANALYS 10 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81433 HEREDITARY BRST CA-RELATED DUP DEL ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81434 HEREDITARY RETINAL DSRDRS GEN SEQ ANALYS 15 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81435 HEREDITARY COLON CA DSRDRS GEN SEQ ANALYS 10 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81436 HEREDITARY COLON CA DSRDRS DUP DEL ANALYS 5 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81437 HEREDTRY NURONDCRN TUM DSRDRS GEN SEQ ANAL 6 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81438 HEREDTRY NURONDCRN TUM DSRDRS DUP DEL ANALYSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81439 HEREDITARY CARDIOMYOPATHY GEN SEQ ANALYS 5 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81440 NUCLEAR MITOCHONDRIAL 100 GENE GENOMIC SEQ Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81442 NOONAN SPECTRUM DISORDERS GEN SEQ ANALYS 12 GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81443 GENETIC TESTING FOR SEVERE INHERITED CONDITIONS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81445 GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

30



Genetic Counseling & Testing 81448 HEREDITARY PERIPHERAL NEUROPATHY GEN SEQ PNL Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81450 GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81455 GEN SEQ ANALYS SOL ORG HEMTOLMPHOID NEO 51 OR GRT GEN Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81460 WHOLE MITOCHONDRIAL GENOME Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81465 WHOLE MITOCHONDRIAL GENOME ANALYSIS PANEL Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81470 X-LINKED INTELLECTUAL DBLT GENOMIC SEQ ANALYS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81471 X-LINKED INTELLECTUAL DBLT DUP DEL GENE ANALYS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81490 AUTOIMMUNE RHEUMATOID ARTHRTS ANALYS 12 BIOMRKRS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81493 COR ART DISEASE MRNA GENE EXPRESSION 23 GENES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81500 ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81503 ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81504 ONCOLOGY TISSUE OF ORIGIN SIMILAR SCOR ALGORITHM Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81507 FETAL ANEUPLOIDY 21 18 13 SEQ ANALY TRISOM RISK Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81518 ONCOLOGY BREAST MRNA GENE EXPRESSION 11 GENES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81519 ONCOLOGY BREAST MRNA GENE EXPRESSION 21 GENES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81520 ONC BREAST MRNA GENE XPRSN PRFL HYBRD 58 GENES Y Prior Authorization required, EXCEPT with breast CA Dx. [ICD10 codes: C50 - C50.929 and D05 - D05.92], see diagnosis tab for additional information

Genetic Counseling & Testing 81521 ONC BREAST MRNA MICRORA GENE XPRSN PRFL 70 GENES Y Prior Authorization required, EXCEPT with breast CA Dx. [ICD10 codes: C50 - C50.929 and D05 - D05.92], see diagnosis tab for additional information

Genetic Counseling & Testing 81522 Oncology (breast) , mRNA , gene expressio n profiling by RT-PCR o f 12 genes (8 content an d 4 housekeeping) , utilizing formalin-fixed paraffin-embedde d tissue , algorithm reporte d as recurrence ris k

Y

Genetic Counseling & Testing 81525 ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing 81535 ONCOLOGY GYNE LIVE TUM CELL CLTR AND CHEMO RESP 1ST Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.




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32



Geneti c Counselin g & Testing 0004M SCOLIOSI S 53 SNP S SALIV A PROGNOSTI C RIS K SCORE Y Excep t fo r Prenata l diagnoses o f congenita l disorder s o f the unbor n chil d through amniocentesi s an d geneti c te st screenin g o f newborn s mandate d b y State regulations.

Genetic Counseling & Testing 0005U ONCO PRST8 GENE XPRS PRFL 3 GENE UR ALG RSK SCOR Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0006M ONCOLOGY HEP MRNA 161 GENES RISK CLASSIFIER Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 0007M ONCOLOGY GAST RO 51 GENE S NOMOGRA M DISEASE INDE X Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0008U HPYLORI DETECTION AND ANTIBIOTIC RESISTANCE DNA Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0009U ONC BRST CA ERBB2 COPY NUMBER FISH AMP NONAMP Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0010U NFCT DS STRN TYP WHL GENOME SEQUENCING PR ISOL Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screening o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0011M LIVER DIS 10 ASSAYS SERUM ALGORITHM W ASH Y

Genetic Counseling & Testing 0011U RX MNTR DRUGS PRESENT LC-MS MS ORAL FLUID PR DOS Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0012M LIVER DIS 10 ASSAYS SERUM ALGORITHM W NASH Y

Genetic Counseling & Testing 0012U GERMLN DO GENE REARGMT DETCJ DNA WHOLE BLOOD Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0013M ONC MRNA 5 GENES UR ALG RISK RECR UROTHELIAL CA Y

Genetic Counseling & Testing 0013U ONC SLD ORGN NEO GENE REARGMT DNA FRSH FRZN TISS Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0014U HEM HMTLMF NEO GENE REARGMT DNA WHL BLD MARROW Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0016U ONC HMTLMF NEO RNA BCR ABL1 BLD BNE MARROW Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0017U ONC HMTLMF NEO JAK2 MUTATION DNA BLD BNE MARROW Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0018U ONC THYR 10 MICRORNA SEQ PLUS - RSLT MOD HI RSK MAL Y

Genetic Counseling & Testing 0019U ONC RNA WHL TRANSCIPTOME SEQ TISS PREDCT ALG Y

Genetic Counseling & Testing 0022U TRGT GEN SEQ ALYS NONSM LNG NEO DNA AND RNA 23 GENES Y Except fo r Prenata l diagnoses of congenita l disorders of the unbor n chil d through amniocentesis an d genetic test screening of newborns mandate d by State regulations.

Genetic Counseling & Testing 0026U ONC THYR DNA AND MRNA 112 GENES FNA NDUL ALG ALYS Y Except fo r Prenata l diagnoses of congenita l disorders of the unbor n chil d through amniocentesis an d genetic test screening of newborns mandate d by State regulations.

Genetic Counseling & Testing 0027U JAK2 GENE ANALYSIS TRGT SEQ ALYS EXONS 12-15 Y Except fo r Prenata l diagnoses of congenita l disorders of the unbor n chil d through amniocentesis an d genetic test screening of newborns mandate d by State regulations.

Genetic Counseling & Testing 0029U RX METAB ADVRS RX RX N AND RSPSE TRG T SEQ ALYS Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.









Geneti c Counselin g & Testing 0030U RX METAB WARFARIN RX RESPONSE TRGT SEQ ALYS Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0031U CYP1A2 GENE ANALYSIS COMMON VARIANTS Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0032U COMT GENE ANALYSIS C.472G OVER A VARIANT Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Geneti c Counselin g & Testing 0033U HTR2A HTR2C GENE ANALYSIS COMMON VARIANTS Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 0034U TPMT NUDT15 GENE ANALYSIS COMMON VARIANTS Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0036U EXOME TUMOR TISSUE AND NORMAL SPECIMEN SEQ ALYS Y

Genetic Counseling & Testing 0037U TRGT GEN SEQ ALYS SLD ORGN NEO DNA 324 GENES Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0045U ONC BRST DUX CARC IS MRNA 12 GENES ALG RSK SCOR Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0046U FLT3 GENE INT TANDEM DUPL VARIANTS QUANTITATIVE Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0047U ONC PRST8 MRNA GEN XPRS PRFL 17 GEN ALG RSK SCOR Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0048U ONC SLD ORG NEO DNA 468 CANCER ASSOCIATED GENES Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0049U NPM1 GENE ANALYSIS QUANTITATIVE Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0050U TRGT GEN SEQ ALYS AML 194 GENE INTERROG SEQ VRNT Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0053U ONC PRST8 CA FISH ALYS 4 GENES NDL BX SPEC ALG Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0055U CARD HRT TRNSPL 96 TARGET DNA SEQUENCES PLASMA Y Except fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d genetic test screening o f newborns mandate d by State regulations.

Genetic Counseling & Testing 0056U HEM AML DNA GENE REARRANGEMENT BLOOD BONE MARROW Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 0058U ONC MERKEL CELL CARC DETCJ ANTB SERUM QUAN Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counselin g & Testing 0059U ONC MERKEL CELL CARC DETCJ ANTB SERUM REPRTD PLUS - Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0060U TWN ZYG GEN TRGT SEQ ALYS CHRMS2 FTL DNA MAT BLD Y Excep t fo r Prenata l diagnoses o f congenita l disorders o f the unbor n chil d through amniocentesis an d geneti c te st screenin g o f newborns mandate d b y State regulations.

Genetic Counseling & Testing 0067U ONC BRST IMHCHEM PRTN XPRS PRFL 4 BMRK CA PRTN Y

Genetic Counseling & Testing 0069U ONC CLRCT MICRORNA XPRS PRFL MIR-31-3P ALG Y

Genetic Counseling & Testing 0070U CYP2D6 GENE ANALYSIS COMMON AND SELECT RARE VRNTS Y



Geneti c Counselin g & Testing 0071U CYP2D6 GENE ANALYSIS FULL GENE SEQUENCE Y

Genetic Counseling & Testing 0072U CYP2D6 GENE TRGT SEQ ALYS CYP2D6-2D7 HYBRID GENE Y

Genetic Counseling & Testing 0073U CYP2D6 GENE TRGT SEQ ALYS CYP2D7-2D6 HYBRID GENE Y

Genetic Counseling & Testing 0074U CYP2D6 TRGT SEQ ALYS NONDUP GENE DUPL MLT TRANS Y

Genetic Counseling & Testing 0075U CYP2D6 GENE TRGT SEQ ALYS 5' GENE DUPL MLT Y

Genetic Counseling & Testing 0076U CYP2D6 GENE TRGT SEQ ALYS 3' GENE DUPL MLT Y

Genetic Counseling & Testing 0078U PAIN MGT OPIOID USE DO GNOTYP PNL 16 CMN VRNTS Y

Genetic Counseling & Testing 0079U CMPRTV DNA ALYS MLT SNPS UR AND BUCCAL SPEC ID VERIF Y

Genetic Counseling & Testing 0084U RBS DNA GNOTYP 10 BLD GRP PHNT PREDICT 37 RBC AG Y

Genetic Counseling & Testing 0087U CARD HRT TRNSPL MRNA GEN XPRS PRFL 1283 GENE ALG Y

Genetic Counseling & Testing 0088U TRNSPL J MED KDN ALGRFT REJ 1494 GENE ALG Y

Genetic Counseling & Testing 0089U ONC MLNMA GEN XPRS PRFL RTQPCR PRAME AND LINC00518 Y

Genetic Counseling & Testing 0090U ONC CUTAN MLNMA MRNA GEN XPRS PRFL 23 GENE ALG Y

Genetic Counseling & Testing 0094U GENOME RAPID SEQUENCE ANALYSIS Y

Genetic Counseling & Testing 0101U HERED COLON CA DO GEN SEQ ALYS PNL 15 GENE Y

Genetic Counseling & Testing 0102U HERED BRST CA RLTD DO GEN SEQ ALYS PNL 17 GENE Y

Genetic Counseling & Testing 0103U HERED OVARIAN CA GEN SEQ ALYS PANEL 24 GENE Y

Genetic Counseling & Testing 0111U ONCOLOGY COLON CA TRGT KRAS AND NRAS GENE ALYS Y

Genetic Counseling & Testing 0113U ONCOLOGY PROSTATE MEAS PCA3 AND TMPRSS2-ERG UR AND PSA SRM

Y

Genetic Counseling & Testing 0114U GI BARRETS ESOPHAGUS VIM AND CCNA1 MTHYLTN ALYS ALG Y

Genetic Counseling & Testing 0118U TRANSPLANT MED QUAN DON-DRV CLL-FR DNA PLSM Y

Genetic Counseling & Testing 0120U ON B CLL LYMPHM MRNA GENE XPRSN PRFL 58 GEN ALG Y






Geneti c Counselin g & Testing 0129U HERED BRST CA RLTD DO GEN SEQ AND DEL DUP PNL Y

Genetic Counseling & Testing 0130U HERED COLON CA DO TRGT MRAN SEQ ALYS PANEL Y

Genetic Counseling & Testing 0131U HERED BRST CA RLTD DO TRGT MRNA SEQ ALYS 13 GENE Y

Genetic Counseling & Testing 0132U HERED OVA CA RLTD DO TRGT MRNA SEQ ALYS 17 GENE Y

Genetic Counseling & Testing 0133U HERED PROSTATE CA RLTD DO TRGT MRNA SEQ ALYS 11 GENE Y

Genetic Counseling & Testing 0134U HERED PAN CA GEN SEQ ALYS PANEL 18 GENE Y Geneti c Counselin g & Testing 0135U HERED GY N C A TRG T MRN A SEQ ALY S 12 GENE Y

Genetic Counseling & Testing 0136U ATM MRNA SEQ ALYS Y

Genetic Counseling & Testing 0137U PALB2 MRNA SEQ ALYS Y

Genetic Counseling & Testing 0138U BRCA1 BRCA2 MRNA SEQ ALYS Y

Geneti c Counselin g & Testing 0139U Neurolog y (autism spectrum disorde r [ASD]) , quantitative measurement s o f 6 centra l carbo n metabolite s (ie , a-ketoglutarate , alanine , lactate , phenylalanine , pyruvate , an d succinate) , LC-

Y

Geneti c Counselin g & Testing 0140U Infectiou s disease (fungi) , funga l pathoge n identification , DN A (1 5 funga l targets) , bloo d culture , amplifie d probe technique , each targe t reporte d as detecte d o r no t detected

Y

Geneti c Counselin g & Testing 0141U Infectiou s disease (bacteri a an d fungi) , gram-positive organism identificatio n an d dru g resistance elemen t detection , DN A (20 gram-positive bacteria l targets , 4 resistance gene s, 1 pa n gram-negative

Y

Geneti c Counselin g & Testing 0142U Infectiou s disease (bacteri a an d fungi) , gram-negative bacterial identificatio n an d dru g resistance elemen t detection , DN A (21 gram-negative bacteria l target s, 6 resistance gene s, 1 pa n gram-positive

Y

Geneti c Counselin g & Testing 0143U Dru g assay , definitive , 120 o r more drugs o r metabolites , urine , Y Geneti c Counselin g & Testing 0144U Dru g assay , definitive , 160 o r more drugs o r metabolites , urine , Y Genetic Counseling & Testing 0145U Drug assay, definitive, 65 or more drugs or metabolites, urine, Y Genetic Counseling & Testing 0146U Drug assay, definitive, 80 or more drugs or metabolites, urine, by Y Genetic Counseling & Testing 0147U Drug assay, definitive, 85 or more drugs or metabolites, urine, Y Genetic Counseling & Testing 0148U Drug assay, definitive, 100 or more drugs or metabolites, urine, Y Genetic Counseling & Testing 0149U Drug assay, definitive, 60 or more drugs or metabolites, urine, Y Genetic Counseling & Testing 0150U Drug assay, definitive, 120 or more drugs or metabolites, urine, Y Genetic Counseling & Testing 0151U Infectious disease (bacterial or viral respiratory tract infection), Y Genetic Counseling & Testing 0152U Infectious disease (bacteria, fungi, parasites, and DNA viruses), Y Genetic Counseling & Testing 0153U ONC BREAST MRNA GENE EXPRESSION PRFL 101 GENES Y Genetic Counseling & Testing 0154U Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of Y Genetic Counseling & Testing 0155U Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5- Y Genetic Counseling & Testing 0156U COPY NUMBER SEQUENCE ALYS Y Genetic Counseling & Testing 0157U APC MRNA SEQ ALYS Y Genetic Counseling & Testing 0158U MLH1 MRNA SEQ ALYS Y Genetic Counseling & Testing 0159U MSH2 MRNA SEQ ALYS Y Genetic Counseling & Testing 0160U MSH6 MRNA SEQ ALYS Y Genetic Counseling & Testing 0161U PMS2 MRNA SEQ ALYS Y Genetic Counseling & Testing 0162U HERED COLON CA TARGETED MRNA SEQUENCE ALYS PANEL Y Genetic Counseling & Testing 0169U NUDT15 AND TPMT GENE ANALYSIS COMMON VARIANTS Y Genetic Counseling & Testing 0170U NEURO ASD RNA NEXT-GNRJ SEQ SALIVA ALG ALYS Y Genetic Counseling & Testing 0171U TARGETED GENOMIC SEQUENCE ALYS PNL DNA 23 GENES Y Genetic Counseling & Testing 0172U Oncology (solid tumor as indicated by the label), somatic mutation Y Genetic Counseling & Testing 0173U Psychiatry (ie, depression, anxiety), genomic analysis panel, Y Genetic Counseling & Testing 0174U Oncology (solid tumor), mass spectrometric 30 protein targets, Y






Genetic Counseling & Testing 0175U Psychiatry (eg, depression, anxiety), genomic analysis panel, variant Y Genetic Counseling & Testing 0176U CDTB & VINCULIN IGG ANTB IA Y

Genetic Counseling & Testing 0177U Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol -4,5- Y Genetic Counseling & Testing 0178U Peanut allergen-specific quantitative assessment of multiple Y Genetic Counseling & Testing 0179U Oncology (non-small cell lung cancer), cell-free DNA, targeted Y Genetic Counseling & Testing 0180U Red cell antigen (ABO blood group) genotyping (ABO), gene analysis Y Genetic Counseling & Testing 0181U Red cell antigen (Colton blood group) genotyping (CO), gene Y Genetic Counseling & Testing 0182U Red cell antigen (Cromer blood group) genotyping (CROM), gene Y Genetic Counseling & Testing 0183U Red cell antigen (Diego blood group) genotyping (DI), gene analysis, Y Genetic Counseling & Testing 0184U Red cell antigen (Dombrock blood group) genotyping (DO), gene Y Genetic Counseling & Testing 0185U Red cell antigen (H blood group) genotyping (FUT1), gene analysis, Y Genetic Counseling & Testing 0186U Red cell antigen (H blood group) genotyping (FUT2), gene analysis, Y Genetic Counseling & Testing 0187U Red cell antigen (Duffy blood group) genotyping (FY), gene analysis, Y Genetic Counseling & Testing 0188U Red cell antigen (Gerbich blood group) genotyping (GE), gene Y Genetic Counseling & Testing 0189U Red cell antigen (MNS blood group) genotyping (GYPA), gene Y Genetic Counseling & Testing 0190U Red cell antigen (MNS blood group) genotyping (GYPB), gene Y Genetic Counseling & Testing 0191U Red cell antigen (Indian blood group) genotyping (IN), gene Y Genetic Counseling & Testing 0192U Red cell antigen (Kidd blood group) genotyping (JK), gene analysis, Y Genetic Counseling & Testing 0193U Red cell antigen (JR blood group) genotyping (JR), gene analysis, Y Genetic Counseling & Testing 0194U Red cell antigen (Kell blood group) genotyping (KEL), gene analysis, Y Genetic Counseling & Testing 0195U KLF1 (Kruppel-like factor 1), targeted sequencing(ie, exon 13) Y Genetic Counseling & Testing 0196U Red cell antigen (Lutheran blood group) genotyping (LU), gene Y Genetic Counseling & Testing 0197U Red cell antigen (Landsteiner-Wiener blood group) genotyping Y Genetic Counseling & Testing 0198U Red cell antigen (RH blood group) genotyping (RHD and RHCE), gene

analysis Sanger/chain termination/conventional sequencing, RHD Y

Genetic Counseling & Testing 0199U Red cell antigen (Scianna blood group) genotyping (SC), gene Y Genetic Counseling & Testing 0200U Red cell antigen (Kx blood group) genotyping (XK), gene analysis, XK

(Xlinked Kx blood group) exons 1 -3 Y

Genetic Counseling & Testing 0201U Red cell antigen (Yt blood group) genotyping (YT), gene analysis, Y Genetic Counseling & Testing G9143 WARFARIN RSPN TEST GEN TECH ANY METH ANY # SPEC Y Except for Prenatal diagnoses of congenital disorders of the unborn child through

amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3800 GENETIC TESTING AMYOTROPHIC LATERAL SCLEROSIS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3840 DNA ANALYSIS GERMLINE MUTATS RET PROTO-ONCOGENE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3841 GENETIC TESTING FOR RETINOBLASTOMA Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3842 GENETIC TESTING FOR VON HIPPEL-LINDAU DISEASE Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3844 DNA ANALY CONNEXIN 26 GENE CONGN PFND DEAFNESS Y Genetic Counseling & Testing S3845 GENETIC TESTING FOR ALPHA-THALASSEMIA Y Genetic Counseling & Testing S3846 GENETIC TESTING HEMOGLOBIN E BETA-THALASSEMIA Y Genetic Counseling & Testing S3850 GENETIC TESTING FOR SICKLE CELL ANEMIA Y Genetic Counseling & Testing S3852 DNA ANALY APOE EPSILON 4 ALLELE SUSECPT ALZS DZ Y Except for Prenatal diagnoses of congenital disorders of the unborn child through

amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3854 GENE EXPRESSION PROFILING PANL MGMT BREAST CA TX Y Prio r Authorizatio n required , EXCEP T wit h brea st C A Dx. [ICD10 codes : C50 - C50.929 and D05 - D05.92] , see diagnosis ta b fo r additiona l information

Genetic Counseling & Testing S3861 GENETIC TESTING SCN5A AND VARIANTS FOR SUSPCTED BS Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3865 COMP GENE SEQ ANALY HYPERTROPHIC CARDIOMYOPATHY Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Genetic Counseling & Testing S3866 GENETIC ANALY GENE MUTAT HCM INDIV KNOWN HCM FAM Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.






Genetic Counseling & Testing S3870 CGH MICROARRAY TEST DD ASD AND OR INTELL DISABILTY Y Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations.

Healthcare Administered Drugs 90281 IMMUNE GLOBULIN IG HUMAN IM USE Y Healthcare Administered Drugs 90283 IMMUNE GLOBULIN IGIV HUMAN IV USE Y

Healthcare Administered Drugs 90284 IMMUNE GLOBULIN HUMAN SUBQ INFUSION 100 MG EA Y

Healthcare Administered Drugs 90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use

Y

Healthcare Administered Drugs 90371 Hepatitis B immune globulin (HBIg), human, for intramuscular use Y

Healthcare Administered Drugs 90378 RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E Y Healthcare Administered Drugs A9542 INDIUM IN-111 IBRITUMOMAB TIUXETAN DX TO 5 MCI Y Healthcare Administered Drugs A9604 Samarium Sm-153 lexidronam, therapeutic, per treatment dose, up Y Healthcare Administered Drugs B4105 IN-LINE CART CTG DIG ENZYME ENTERAL FEEDING EA Y Healthcare Administered Drugs B4187 Omegaven, 10 g lipids Y

Healthcare Administered Drugs C9047 INJECTION CAPLACIZUMAB-YHDP 1 MG Y Healthcare Administered Drugs C9122 MOMETASONE FUROATE SINUS IMPLANT, 10 micrograms (sinuva) Y Healthcare Administered Drugs C9132 PROTHROMBIN CMPLX CONC KCENTRA I.U. FCT IX ACTV Y Medicaid only Healthcare Administered Drugs C9257 INJECTION BEVACIZUMAB 0.25 MG Y No PA required when associated with ocular Dx's. Healthcare Administered Drugs C9293 INJECTION GLUCARPIDASE 10 UNITS Y Healthcare Administered Drugs C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS Y Healthcare Administered Drugs C9488 INJECTION CONIVAPTAN HYDROCHLORIDE 1 MG Y Healthcare Administered Drugs J0121 INJECTION OMADACYCLINE 1 MG Y Healthcare Administered Drugs J0122 Injection, eravacycline, 1 mg Y

Healthcare Administered Drugs J0129 INJ ABATACEPT 10 MG USED MEDICARE ADM SUPV PHYS Y Healthcare Administered Drugs J0135 INJECTION ADALIMUMAB 20 MG Y Healthcare Administered Drugs J0178 INJECTION AFLIBERCEPT 1 MG Y Healthcare Administered Drugs J0179 Injection, brolucizumab-dbll, 1 mg Y Healthcare Administered Drugs J0180 INJECTION AGALSIDASE BETA 1 MG Y Healthcare Administered Drugs J0202 INJECTION ALEMTUZUMAB 1 MG Y

Healthcare Administered Drugs J0205 INJECTION ALGLUCERASE PER 10 UNITS Y

Healthcare Administered Drugs J0207 INJECTION AMIFOSTINE 500 MG Y

Healthcare Administered Drugs J0220 INJECTION ALGLUCOSIDASE ALFA 10 MG NOS Y Healthcare Administered Drugs J0221 INJECTION ALGLUCOSIDASE ALFA LUMIZYME 10 MG Y Healthcare Administered Drugs J0222 INJECTION PATISIRAN 0.1 MG Y Healthcare Administered Drugs J0223 INJECTION, GIVOSIRAN, 0.5 mg Y Healthcare Administered Drugs J0256 INJECTION ALPHA 1-PROTASE INHIBITOR NOS 10 MG Y Healthcare Administered Drugs J0257 INJECTION ALPHA 1 PROTEINASE INHIBITOR 10 MG Y Healthcare Administered Drugs J0285 Injection, amphotericin B, 50 mg Y Healthcare Administered Drugs J0287 INJECTION AMPHOTERICIN B LIPID COMPLEX 10 MG Y Healthcare Administered Drugs J0289 INJECTION AMPHOTERICIN B LIPOSOME 10 MG Y Healthcare Administered Drugs J0291 INJECTION PLAZOMICIN 5 MG Y

Healthcare Administered Drugs J0364 INJECTION APOMORPHINE HYDROCHLORIDE 1 MG Y

Healthcare Administered Drugs J0480 INJECTION BASILIXIMAB 20 MG Y Healthcare Administered Drugs J0485 INJECTION BELATACEPT 1 MG Y Healthcare Administered Drugs J0490 INJECTION BELIMUMAB 10 MG Y Healthcare Administered Drugs J0517 INJECTION BENRALIZUMAB 1 MG Y Healthcare Administered Drugs J0565 INJECTION BEZLOTOXUMAB 10 MG Y Healthcare Administered Drugs J0567 INJECTION CERLIPONASE ALFA 1 MG Y Healthcare Administered Drugs J0570 BUPRENORPHINE IMPLANT 74.2 MG Y Healthcare Administered Drugs J0584 INJECTION BUROSUMAB-TWZA 1 MG Y Healthcare Administered Drugs J0585 BOTULINUM TOXIN TYPE A PER UNIT Y Healthcare Administered Drugs J0586 INJECTION ABOBOTULINUMTOXINA 5 UNITS Y Healthcare Administered Drugs J0587 INJECTION RIMABOTULINUMTOXINB 100 UNITS Y






Healthcare Administered Drugs J0588 INJECTION INCOBOTULINUMTOXIN A 1 UNIT Y Healthcare Administered Drugs J0592 Injection, buprenorphine HCl, 0.1 mg Y Y Healthcare Administered Drugs J0593 INJECTION, LANADELUMAB-FLYO 1 mg Y Healthcare Administered Drugs J0594 INJECTION BUSULFAN 1 MG Y Healthcare Administered Drugs J0596 INJECTION C1 ESTERASE INHIBITOR RUCONEST 10 U Y Healthcare Administered Drugs J0597 INJ C-1 ESTERASE INHIB HUMN BERINERT 10 UNITS Y Healthcare Administered Drugs J0598 INJECTION C1 ESTERASE INHIBITOR CINRYZE 10 UNITS Y Healthcare Administered Drugs J0599 INJECTION C-1 ESTERASE INHIBITOR 10 UNITS Y Healthcare Administered Drugs J0604 CINACALCET ORAL 1 MG Y Healthcare Administered Drugs J0606 INJECTION ETELCALCETIDE 0.1 MG Y Healthcare Administered Drugs J0637 INJECTION CASPOFUNGIN ACETATE 5 MG Y Healthcare Administered Drugs J0638 INJECTION CANAKINUMAB 1 MG Y Healthcare Administered Drugs J0641 INJECTION LEVOLEUCOVORIN CALCIUM 0.5 MG Y Healthcare Administered Drugs J0642 Injection, levoleucovorin (Khapzory), 0.5 mg Y Healthcare Administered Drugs J0691 INJECTION, LEFAMULIN, 1 mg Y Healthcare Administered Drugs J0695 INJECTION CEFTOLOZANE 50 MG AND TAZOBACTAM 25 MG Y Healthcare Administered Drugs J0712 Injection, ceftaroline fosamil, 10 mg Y Healthcare Administered Drugs J0714 INJECTION CEFTAZIDIME AND AVIBACTAM 0.5 G 0.125 G Y Healthcare Administered Drugs J0717 INJECTION CERTOLIZUMAB PEGOL 1 MG Y Healthcare Administered Drugs J0725 INJECTION CHORIONIC GONADOTROPIN-1000 USP UNITS Y Healthcare Administered Drugs J0740 Injection, cidofovir, 375 mg Y Y Healthcare Administered Drugs J0775 INJ COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 0.01 MG Y Healthcare Administered Drugs J0791 INJECTION, CRIZANLIZUMAB-TMCA, 5 mg Y Healthcare Administered Drugs J0800 INJECTION CORTICOTROPIN UP TO 40 UNITS Y Healthcare Administered Drugs J0841 INJECTION CROTALIDAE IMMUNE F120 MG Y Healthcare Administered Drugs J0850 INJECTION CYTOMEGALOVIRUS IMMUNE GLOB IV-VIAL Y Healthcare Administered Drugs J0875 INJECTION DALBAVANCIN 5MG Y Healthcare Administered Drugs J0878 INJECTION DAPTOMYCIN 1 MG Y Healthcare Administered Drugs J0881 INJECTION DARBEPOETIN ALFA 1 MCG NON-ESRD USE Y Healthcare Administered Drugs J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) Y Y Healthcare Administered Drugs J0885 INJECTION EPOETIN ALFA FOR NON-ESRD 1000 UNITS Y Healthcare Administered Drugs J0888 INJECTION EPOETIN BETA 1 MICROGRAM Y Healthcare Administered Drugs J0894 INJECTION DECITABINE 1 MG Y Healthcare Administered Drugs J0895 INJECTION DEFEROXAMINE MESYLATE 500 MG Y Healthcare Administered Drugs J0896 INJECTION, LUPATERCEPT-AAMT, 0.25 mg Y Healthcare Administered Drugs J0897 INJECTION DENOSUMAB 1 MG Y Healthcare Administered Drugs J1095 INJECTION DEXAMETHASONE 9PCT INTRAOCULAR 1 MCG Y Healthcare Administered Drugs J1096 DEXAMETHASONE LACRIMAL OPHTHALMIC INSERT 0.1 MG Y Healthcare Administered Drugs J1230 INJECTION METHADONE HCL UP TO 10 MG Y Healthcare Administered Drugs J1290 INJECTION ECALLANTIDE 1 MG Y Healthcare Administered Drugs J1300 INJECTION ECULIZUMAB 10 MG Y Healthcare Administered Drugs J1301 INJECTION EDARAVONE 1 MG Y Healthcare Administered Drugs J1303 INJECTION RAVULIZUMAB-CWVZ 10 MG Y Healthcare Administered Drugs J1322 INJECTION ELOSULFASE ALFA 1 MG Y Healthcare Administered Drugs J1324 INJECTION ENFUVIRTIDE 1 MG Y Healthcare Administered Drugs J1325 INJECTION EPOPROSTENOL 0.5 MG Y Healthcare Administered Drugs J1428 INJECTION ETEPLIRSEN 10 MG Y Healthcare Administered Drugs J1429 INJECTION, GOLODIRSEN, 10 mg Y Healthcare Administered Drugs J1437 INJECTION, FERRIC DERISOMALTOSE, 10MG Y Healthcare Administered Drugs J1438 INJECTION ETANERCEPT 25 MG Y Healthcare Administered Drugs J1439 INJECTION FERRIC CARBOXYMALTOSE 1 MG Y Healthcare Administered Drugs J1442 INJECTION FILGRASTIM EXCLUDES BIOSIMILARS 1 MIC Y Healthcare Administered Drugs J1447 INJECTION TBO-FILGRASTIM 1 MICROGRAM Y Healthcare Administered Drugs J1454 INJ FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG Y Healthcare Administered Drugs J1458 INJECTION GALSULFASE 1 MG Y Healthcare Administered Drugs J1459 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG Y Healthcare Administered Drugs J1460 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 1 CC Y Healthcare Administered Drugs J1555 INJECTION IMMUNE GLOBULIN 100 MG Y Healthcare Administered Drugs J1556 INJECTION IMMUNE GLOBULIN BIVIGAM 500 MG Y Healthcare Administered Drugs J1557 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG Y Healthcare Administered Drugs J1558 INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 mg Y Healthcare Administered Drugs J1559 INJECTION IMMUNE GLOBULIN HIZENTRA 100 MG Y Healthcare Administered Drugs J1560 INJECTION GAMMA GLOB INTRAMUSCULAR OVER 10 CC Y Healthcare Administered Drugs J1561 INJECTION IMMUNE GLOBULIN NONLYOPHILIZED 500 MG Y Healthcare Administered Drugs J1562 INJECTION IMMUNE GLOBULIN VIVAGLBIN 100 MG Y






Healthcare Administered Drugs J1566 INJ IG IV LYPHILIZED NOT OTHERWISE SPEC 500 MG Y Healthcare Administered Drugs J1568 INJ IG OCTOGAM IV NONLYOPHILIZED 500 MG Y Healthcare Administered Drugs J1569 INJ IG GAMMAGARD LIQ IV NONLYOPHILIZED 500 MG Y Healthcare Administered Drugs J1570 INJECTION GANCICLOVIR SODIUM 500 MG Y Healthcare Administered Drugs J1571 INJ HEPATITIS B IG HEPAGAM B IM 0.5 ML Y Healthcare Administered Drugs J1572 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG Y Healthcare Administered Drugs J1573 INJ HEP B IG HEPAGAM B INTRAVENOUS 0.5 ML Y Healthcare Administered Drugs J1575 INJ IMMUNE GLOBULIN HYALURONIDASE 100 MG IG Y Healthcare Administered Drugs J1595 INJECTION GLATIRAMER ACETATE 20 MG Y Healthcare Administered Drugs J1599 INJ IG IV NONLYOPHILIZED E.G. LIQUID NOS 500 MG Y Healthcare Administered Drugs J1602 INJECTION GOLIMUMAB 1 MG FOR INTRAVENOUS USE Y Healthcare Administered Drugs J1627 INJECTION GRANISETRON EXTENDED-RELEASE 0.1 MG Y Healthcare Administered Drugs J1628 INJECTION GUSELKUMAB 1 MG Y Healthcare Administered Drugs J1632 INJECTION, BREXANOLONE, 1 MG Y Healthcare Administered Drugs J1640 INJECTION HEMIN 1 MG Y Healthcare Administered Drugs J1645 INJECTION DALTEPARIN SODIUM PER 2500 IU Y Healthcare Administered Drugs J1652 INJECTION FONDAPARINUX SODIUM 0.5 MG Y Healthcare Administered Drugs J1675 INJECTION HISTRELIN ACETATE 10 MICROGRAMS Y Healthcare Administered Drugs J1726 INJECTION HYDROXYPROGESTERONE CAPROATE 10 MG Y Healthcare Administered Drugs J1729 INJECTION HYDROXYPROGESTERONE CAPROATE NOS 10 MG Y Healthcare Administered Drugs J1740 INJECTION IBANDRONATE SODIUM 1 MG Y Healthcare Administered Drugs J1743 INJECTION IDURSULFASE 1 MG Y Healthcare Administered Drugs J1744 INJECTION ICATIBANT 1 MG Y Healthcare Administered Drugs J1745 INJECTION INFLIXIMAB EXCLUDES BIOSIMILAR 10 MG Y Healthcare Administered Drugs J1746 INJECTION IBALIZUMAB-UIYK 10 MG Y Healthcare Administered Drugs J1786 INJECTION IMIGLUCERASE 10 UNITS Y Healthcare Administered Drugs J1826 INJECTION INTERFERON BETA-1A 30 MCG Y Healthcare Administered Drugs J1830 INJECTION INTERFERON BETA-1B 0.25 MG Y Healthcare Administered Drugs J1833 INJECTION ISAVUCONAZONIUM 1 MG Y Healthcare Administered Drugs J1930 INJECTION LANREOTIDE 1 MG Y Healthcare Administered Drugs J1931 INJECTION LARONIDASE 0.1 MG Y Healthcare Administered Drugs J1943 INJECTION ARIPIPRAZOLE LAUROXIL 1 MG Y Healthcare Administered Drugs J1950 INJECTION LEUPROLIDE ACETATE PER 3.75 MG Y Healthcare Administered Drugs J1955 INJECTION LEVOCARNITINE PER 1 G Y Healthcare Administered Drugs J2020 INJECTION LINEZOLID 200 MG Y Healthcare Administered Drugs J2062 LOXAPINE FOR INHALATION 1 MG Y Healthcare Administered Drugs J2170 INJECTION MECASERMIN 1 MG Y Healthcare Administered Drugs J2182 INJECTION MEPOLIZUMAB 1 MG Y Healthcare Administered Drugs J2186 INJECTION MEROPENEM VABORBACTAM 10 MG 10 MG Y Healthcare Administered Drugs J2212 Injection, methylnaltrexone, 0.1 mg Y Y Healthcare Administered Drugs J2248 INJECTION MICAFUNGIN SODIUM 1 MG Y Healthcare Administered Drugs J2323 INJECTION NATALIZUMAB 1 MG Y Healthcare Administered Drugs J2326 INJECTION NUSINERSEN 0.1 MG Y Healthcare Administered Drugs J2350 INJECTION OCRELIZUMAB 1 MG Y Healthcare Administered Drugs J2353 INJ OCTREOTIDE DEPOT FORM IM INJ 1 MG Y Healthcare Administered Drugs J2354 INJ OCTREOTIDE NON-DEPOT FORM SUBQ IV INJ 25 MCG Y Healthcare Administered Drugs J2357 INJECTION OMALIZUMAB 5 MG Y Healthcare Administered Drugs J2407 Injection, oritavancin, 10 mg Y Healthcare Administered Drugs J2425 INJECTION PALIFERMIN 50 MICROGRAMS Y Healthcare Administered Drugs J2430 Injection, pamidronate disodium, per 30 mg Y Y Healthcare Administered Drugs J2440 Injection, papaverine HCl, up to 60 mg Y Y Healthcare Administered Drugs J2502 INJECTION PASIREOTIDE LONG ACTING 1 MG Y Healthcare Administered Drugs J2503 INJECTION PEGAPTANIB SODIUM 0.3 MG Y Healthcare Administered Drugs J2504 INJECTION PEGADEMASE BOVINE 25 IU Y Healthcare Administered Drugs J2505 INJECTION PEGFILGRASTIM 6 MG Y Healthcare Administered Drugs J2507 INJECTION PEGLOTICASE 1 MG Y Healthcare Administered Drugs J2562 INJECTION PLERIXAFOR 1 MG Y Healthcare Administered Drugs J2597 INJECTION DESMOPRESSIN ACETATE PER 1 MCG Y Healthcare Administered Drugs J2724 INJECTION PROTEN C CONCENTRATE IV HUMAN 10 IU Y Healthcare Administered Drugs J2770 Injection, quinupristin/dalfopristin, 500 mg (150/350) Y Healthcare Administered Drugs J2778 INJECTION RANIBIZUMAB 0.1 MG Y Healthcare Administered Drugs J2783 INJECTION RASBURICASE 0.5 MG Y Healthcare Administered Drugs J2786 INJECTION RESLIZUMAB 1 MG Y Healthcare Administered Drugs J2787 RIBOFLAVIN 5'-PHOSPHATE OPHTHALMIC SOL TO 3 ML Y Healthcare Administered Drugs J2793 INJECTION RILONACEPT 1 MG Y






Healthcare Administered Drugs J2796 INJECTION ROMIPLOSTIM 10 MCG Y Healthcare Administered Drugs J2797 INJECTION ROLAPITANT 0.5 MG Y Healthcare Administered Drugs J2820 INJECTION SARGRAMOSTIM 50 MCG Y Healthcare Administered Drugs J2840 INJECTION SEBELIPASE ALFA 1 MG Y Healthcare Administered Drugs J2860 INJECTION SILTUXIMAB 10 MG Y Healthcare Administered Drugs J2940 Injection, somatrem, 1 mg Y Y Healthcare Administered Drugs J2941 INJECTION SOMATROPIN 1 MG Y Healthcare Administered Drugs J3030 Injection, sumatriptan succinate, 6 mg (code may be used for Y Y Healthcare Administered Drugs J3031 INJECTION FREMANEZUMAB-VFRM 1 MG Y Healthcare Administered Drugs J3032 INJECTION, EPTINEZUMAG-JJMR, 1MG Y Healthcare Administered Drugs J3060 INJECTION TALIGLUCERASE ALFA 10 UNITS Y Healthcare Administered Drugs J3090 INJECTION TEDIZOLID PHOSPHATE 1 MG Y Healthcare Administered Drugs J3095 INJECTION TELAVANCIN 10 MG Y Healthcare Administered Drugs J3110 INJECTION TERIPARATIDE 10 MCG Y Healthcare Administered Drugs J3111 INJECTION, ROMOSOZUMAB-AQQG, 1 mg Y Healthcare Administered Drugs J3145 INJECTION TESTOSTERONE UNDECANOATE 1 MG Y Healthcare Administered Drugs J3241 INJECTION, TEPROTUMUMAB-TRBW, 10MG Y Healthcare Administered Drugs J3245 INJECTION TILDRAKIZUMAB 1 MG Y Healthcare Administered Drugs J3262 INJECTION TOCILIZUMAB 1 MG Y Healthcare Administered Drugs J3285 INJECTION TREPROSTINIL 1 MG Y Healthcare Administered Drugs J3304 INJECT TRIAMCINOLONE ACETONIDE PF ER MS F 1 MG Y Healthcare Administered Drugs J3315 INJECTION TRIPTORELIN PAMOATE 3.75 MG Y Healthcare Administered Drugs J3316 INJECTION TRIPTORELIN EXTENDED-RELEASE 3.75 MG Y Healthcare Administered Drugs J3355 INJECTION UROFOLLITROPIN 75 IU Y Healthcare Administered Drugs J3357 USTEKINUMAB FOR SUBCUTANEOUS INJECTION 1 MG Y Healthcare Administered Drugs J3358 USTEKINUMAB FOR INTRAVENOUS INJECTION 1 MG Y Healthcare Administered Drugs J3380 INJECTION VEDOLIZUMAB 1 MG Y Healthcare Administered Drugs J3385 INJECTION VELAGLUCERASE ALFA 100 UNITS Y

Healthcare Administered Drugs J3396 INJECTION VERTEPORFIN 0.1 MG Y Healthcare Administered Drugs J3397 INJECTION VESTRONIDASE ALFA-VJBK 1 MG Y Healthcare Administered Drugs J3398 INJECTION VORETIGENE NEPARVOVEC-RZYL 1 B VEC G Y Healthcare Administered Drugs J3399 INJECTION, ONASEMNOGENE ABEPARVOVEC, PER TX, UP TO Y Healthcare Administered Drugs J3490 UNCLASSIFIED DRUGS Y Requires Mandatory Medical Director Review Healthcare Administered Drugs J3590 UNCLASSIFIED BIOLOGICS Y Healthcare Administered Drugs J3591 UNCLASS RX BIOLOGICAL USED FOR ESRD ON DIALYSIS Y Healthcare Administered Drugs J7170 INJECTION EMICIZUMAB-KXWH 0.5 MG Y Healthcare Administered Drugs J7175 INJECTION FACTOR X 1 I.U. Y Healthcare Administered Drugs J7177 INJECTION HUMAN FIBRINOGEN CONCENTRATE 1 MG Y Healthcare Administered Drugs J7178 INJECTION HUMAN FIBRINOGEN CONC NOS 1 MG Y Healthcare Administered Drugs J7179 INJECTION VON WILLEBRAND FACTOR 1 I.U. VWF:RCO Y Healthcare Administered Drugs J7180 INJECTION FACTOR XIII 1 I.U. Y Healthcare Administered Drugs J7181 INJECTION FACTOR XIII A-SUBUNIT PER IU Y Healthcare Administered Drugs J7182 INJECTION FACTOR VIII PER IU Y Healthcare Administered Drugs J7183 INJ VON WILLEBRAND FACTR COMPLEX WILATE 1 IU:RCO Y Healthcare Administered Drugs J7185 INJECTION FACTOR VIII PER IU Y Healthcare Administered Drugs J7186 INJ AHF VWF CMPLX PER FACTOR VIII IU Y Healthcare Administered Drugs J7187 INJ VONWILLEBRND FACTOR CMPLX HUMN RISTOCETIN IU Y Healthcare Administered Drugs J7188 INJECTION FACTOR VIII PER I.U. Y Healthcare Administered Drugs J7189 FACTOR VIIA 1 MICROGRAM Y Healthcare Administered Drugs J7190 FACTOR VIII ANTIHEMOPHILIC FACTOR HUMAN PER IU Y Healthcare Administered Drugs J7191 FACTOR VIII ANTIHEMOPHILIC FACTOR PROCINE PER IU Y Healthcare Administered Drugs J7192 FACTOR VIII PER IU NOT OTHERWISE SPECIFIED Y Healthcare Administered Drugs J7193 FACTOR IX AHF PURIFIED NON-RECOMBINANT PER IU Y Healthcare Administered Drugs J7194 FACTOR IX COMPLEX PER IU Y Healthcare Administered Drugs J7195 INJ FACTOR IX PER IU NOT OTHERWISE SPECIFIED Y Healthcare Administered Drugs J7196 INJECTION ANTITHROMBIN RECOMBINANT 50 I.U. Y Healthcare Administered Drugs J7197 ANTITHROMBIN III PER IU Y Healthcare Administered Drugs J7198 ANTI-INHIBITOR PER IU Y Healthcare Administered Drugs J7199 HEMOPHILIA CLOTTING FACTOR NOC Y Healthcare Administered Drugs J7200 INJECTION FACTOR IX RIXUBIS PER IU Y Healthcare Administered Drugs J7201 INJECTION FAC IX FC FUS PROTEIN ALPROLIX 1 I.U. Y Healthcare Administered Drugs J7202 INJECTION FAC IX ALBUMIN FUS PRT IDELVION 1 I.U. Y






Healthcare Administered Drugs J7203 INJECTION FACTOR IX GLYCOPEGYLATED 1 IU Y Healthcare Administered Drugs J7204 INJECTION, FACTOR VIII, ATHIHEMPHILIC FACTOR (RECOMBINANT), Y Healthcare Administered Drugs J7205 INJECTION FACTOR VIII FC FUSION PROTEIN PER IU Y Healthcare Administered Drugs J7207 INJECTION FACTOR VIII PEGYLATED 1 I.U. Y Healthcare Administered Drugs J7208 INJECTION FACTOR VIII PEGYLATED-AUCL 1 IU Y Healthcare Administered Drugs J7209 INJECTION FACTOR VIII 1 I.U. Y Healthcare Administered Drugs J7210 INJECTION FACTOR VIII AFSTYLA 1 I.U. Y Healthcare Administered Drugs J7211 INJECTION FACTOR VIII KOVALTRY 1 I.U. Y Healthcare Administered Drugs J7308 AMINOLEVULINIC ACID HCL TOP ADMN 20PCT 1 U DOSE Y Healthcare Administered Drugs J7309 METHYL AMINOLEVULINATE MAL TOP ADMIN 16.8PCT 1 G Y Healthcare Administered Drugs J7310 GANCICLOVIR 4.5 MG LONG-ACTING IMPLANT Y Healthcare Administered Drugs J7311 FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT Y Healthcare Administered Drugs J7312 INJECTION DEXAMETHASONE INTRAVITREAL IMPL 0.1 MG Y Healthcare Administered Drugs J7313 INJECTION FA INTRAVITREAL IMPLANT 0.01 MG Y Healthcare Administered Drugs J7314 INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT Y Healthcare Administered Drugs J7316 INJECTION OCRIPLASMIN 0.125 MG Y Healthcare Administered Drugs J7318 HYALURONAN DERIVATIVE DUROLANE FOR IA INJ 1 MG Y Healthcare Administered Drugs J7320 HYALURONAN DERIVITIVE GENVISC 850 IA INJ 1 MG Y Healthcare Administered Drugs J7321 HYAL DERIV HYALGAN SUPARTZ VISCO-3 IA INJ-DOSE Y Healthcare Administered Drugs J7322 HYALURONAN DERIVATIVE HYMOVIS IA INJ 1 MG Y Healthcare Administered Drugs J7323 HYALURONAN DERIVATIVE EUFLEXXA IA INJ PER DOSE Y Healthcare Administered Drugs J7324 HYALURONAN DERIV ORTHOVISC IA INJ PER DOSE Y Healthcare Administered Drugs J7325 HYALURONAN DERIV SYNVISC SYNVISC-ONE IA INJ 1 MG Y Healthcare Administered Drugs J7326 HYALURONAN DERIV GEL-ONE INTRA-ARTIC INJ PER DOS Y Healthcare Administered Drugs J7327 HYALURONAN DERIVATIVE MONOVISC IA INJ PER DOSE Y Healthcare Administered Drugs J7328 HYALURONAN DERIVATIVE GELSYN-3 FOR IA INJ 0.1 MG Y Healthcare Administered Drugs J7329 HYALURONAN DERIVATIVE TRIVISC FOR IA INJ 1 MG Y Healthcare Administered Drugs J7330 AUTOLOGOUS CULTURED CHONDROCYTES IMPLANT Y Healthcare Administered Drugs J7331 HYALURONAN OR DERIVATIVE, SYNOJOYNT, FOR INTRA-ARTICULAR Y Healthcare Administered Drugs J7332 HYALURONAN OR DERIVATIVE, TRILURON, FOR INTRA-ARTICULAR Y

Healthcare Administered Drugs J7333 HYALURONAN OR DERIVATIVE, VISCO-3, FOR INTRA-ARTICULAR INJ, PER DOSE

Y

Healthcare Administered Drugs J7336 Capsaicin 8% patch, per sq cm Y Healthcare Administered Drugs J7340 CARBIDPA 5 MG LEVODPA 20 MG EN SUSP 100 ML Y Healthcare Administered Drugs J7351 INJECTION, BIMATOPROST, INTRACAMERAL IMPLANT, 1 Y Healthcare Administered Drugs J7401 MOMETASONE FUROATE SINUS IMPLANT, 10 MG Y Healthcare Administered Drugs J7504 LYMPHCYT IMMUN GLOB EQUINE PARENTERAL 250 MG Y Healthcare Administered Drugs J7511 LYMPHCYT IMMUN GLOB RABBIT PARENTERAL 25 MG Y Healthcare Administered Drugs J7527 EVEROLIMUS ORAL 0. 25 MG Y Healthcare Administered Drugs J7639 DORNASE ALFA INHAL SOL NONCOMP UNIT DOSE PER MG Y Healthcare Administered Drugs J7677 REVEFENACIN INHAL SOL NONCOMPND ADM DME 1 MCG Y Healthcare Administered Drugs J7682 TOBRAMYCIN INHAL NON-COMP UNIT DOSE PER 300 MG Y Healthcare Administered Drugs J7686 TREPROSTINIL INHAL SOLUTION UNIT DOSE 1.74 MG Y Healthcare Administered Drugs J8499 PRESCRIPTION DRUG ORAL NONCHEMOTHERAPEUTIC NOS Y Healthcare Administered Drugs J8520 CAPECITABINE ORAL 150 MG Y Healthcare Administered Drugs J8521 CAPECITABINE ORAL 500 MG Y

Healthcare Administered Drugs J8655 NETUPITANT 300 MG AND PALONOSETRON 0.5 MG ORAL Y

Healthcare Administered Drugs J8670 ROLAPITANT ORAL 1 MG Y Healthcare Administered Drugs J8700 TEMOZOLOMIDE ORAL 5 MG Y Healthcare Administered Drugs J8999 PRESCRIPTION DRUG ORAL CHEMOTHERAPEUTIC NOS Y Healthcare Administered Drugs J9015 INJECTION ALDESLEUKIN PER SINGLE USE VIAL Y Healthcare Administered Drugs J9017 INJECTION ARSENIC TRIOXIDE 1 MG Y Healthcare Administered Drugs J9019 INJECTION ASPARAGINASE ERWINAZE 1000 IU Y Healthcare Administered Drugs J9022 INJECTION ATEZOLIZUMAB 10 MG Y Healthcare Administered Drugs J9023 INJECTION AVELUMAB 10 MG Y Healthcare Administered Drugs J9025 INJECTION AZACITIDINE 1 MG Y Healthcare Administered Drugs J9027 INJECTION CLOFARABINE 1 MG Y Healthcare Administered Drugs J9030 BCG LIVE INTRAVESICAL INSTILLATION 1 MG Y Healthcare Administered Drugs J9032 INJECTION BELINOSTAT 10 MG Y Healthcare Administered Drugs J9033 INJECTION BENDAMUSTINE HCL TREANDA 1 MG Y Healthcare Administered Drugs J9034 INJECTION BENDAMUSTINE HCL BENDEKA 1 MG Y Healthcare Administered Drugs J9035 INJECTION BEVACIZUMAB 10 MG Y No PA required when associated with ocular Diagnoses. (See Dx Codes tab for related Healthcare Administered Drugs J9036 INJECTION BENDAMUSTINE HYDROCHLORIDE 1 MG Y






Healthcare Administered Drugs J9039 INJECTION BLINATUMOMAB 1 MICROGRAM Y Healthcare Administered Drugs J9042 INJECTION BRENTUXIMAB VEDOTIN 1 MG Y Healthcare Administered Drugs J9043 INJECTION CABAZITAXEL 1 MG Y Healthcare Administered Drugs J9044 INJECTION BORTEZOMIB NOS 0.1 MG Y Healthcare Administered Drugs J9047 INJECTION CARFILZOMIB 1 MG Y Healthcare Administered Drugs J9050 INJECTION CARMUSTINE 100 MG Y Healthcare Administered Drugs J9057 INJECTION COPANLISIB 1 MG Y Healthcare Administered Drugs J9098 INJECTION CYTARABINE LIPOSOME 10 MG Y Healthcare Administered Drugs J9119 Injection, cemiplimab-rwlc, 1 mg Y Healthcare Administered Drugs J9120 INJECTION DACTINOMYCIN 0.5 MG Y Healthcare Administered Drugs J9145 INJECTION DARATUMUMAB 10 MG Y Healthcare Administered Drugs J9153 INJECTION LIPOSOMAL 1 MG DNR AND 2.27 MG CA Y

Healthcare Administered Drugs J9155 INJECTION DEGARELIX 1 MG Y Healthcare Administered Drugs J9160 INJECTION DENILEUKIN DIFTITOX 300 MCG Y Healthcare Administere d Drugs J9173 INJECTIO N DURVALUMAB 10 M G Y Healthcare Administere d Drugs J9176 INJECTIO N ELOTUZUMAB 1 M G Y Healthcare Administere d Drugs J9177 INJECTION , ENFORTUMAB VEDOTIN-EJFV , 0.25 mg Y Healthcare Administere d Drugs J9179 INJECTIO N ERIBULI N MESYLATE 0.1 M G Y Healthcare Administere d Drugs J9198 INJECTION , GEMCITABINE HYDROCHLORIDE (infugem) , 100 mg Y Healthcare Administere d Drugs J9200 INJECTIO N FLOXURIDINE 500 M G Y Healthcare Administered Drugs J9202 GOSERELIN ACETATE IMPLANT PER 3.6 MG Y Healthcare Administered Drugs J9203 INJECTION GEMTUZUMAB OZOGAMICIN 0.1 MG Y Healthcare Administered Drugs J9204 INJECTION MOGAMULIZUMAB-KPKC 1 MG Y Healthcare Administered Drugs J9205 INJECTION IRINOTECAN LIPOSOME 1 MG Y Healthcare Administered Drugs J9207 INJECTION IXABEPILONE 1 MG Y Healthcare Administered Drugs J9208 INJECTION IFOSFAMIDE 1 G Y Healthcare Administered Drugs J9210 INJECTION EMAPALUMAB-LZSG 1 MG Y Healthcare Administered Drugs J9211 INJECTION IDARUBICIN HCL 5 MG Y Healthcare Administered Drugs J9214 INJECTION INTERFERON ALFA-2B RECOMBINANT 1 M U Y Healthcare Administered Drugs J9215 INJECTION INTERFERON ALFA-N3 250,000 IU Y Healthcare Administered Drugs J9216 INJECTION INTERFERON GAMMA-1B 3 MILLION UNITS Y Healthcare Administered Drugs J9217 LEUPROLIDE ACETATE 7.5 MG Y Healthcare Administered Drugs J9218 LEUPROLIDE ACETATE PER 1 MG Y Healthcare Administered Drugs J9219 LEUPROLIDE ACETATE IMPLANT 65 MG Y Healthcare Administered Drugs J9225 HISTRELIN IMPLANT VANTAS 50 MG Y Healthcare Administered Drugs J9226 HISTRELIN IMPLANT SUPPRELIN LA 50 MG Y Healthcare Administered Drugs J9227 INJECTION, ISATUXIMAB-IRFC, 10 MG Y Healthcare Administered Drugs J9228 INJECTION IPILIMUMAB 1 MG Y Healthcare Administered Drugs J9229 INJECTION INOTUZUMAB OZOGAMICIN 0.1 MG Y Healthcare Administered Drugs J9230 INJECTION MECHLORETHAMINE HCL 10 MG Y Healthcare Administered Drugs J9245 INJECTION MELINJECTION MELPHALAN HCL 50 MG Y Healthcare Administered Drugs J9246 INJECTION, MELPHALAN (evomela), 1 mg Y Healthcare Administered Drugs J9261 INJECTION NELARABINE 50 MG Y Healthcare Administered Drugs J9262 INJECTION OMACETAXINE MEPESUCCINATE 0.01 MG Y Healthcare Administered Drugs J9266 INJECTION PEGASPARGASE PER SINGLE DOSE VIAL Y Healthcare Administered Drugs J9268 INJECTION PENTOSTATIN 10 MG Y Healthcare Administered Drugs J9269 INJECTION TAGRAXOFUSP-ERZS 10 MCG Y Healthcare Administered Drugs J9271 INJECTION PEMBROLIZUMAB 1 MG Y Healthcare Administered Drugs J9280 INJECTION MITOMYCIN 5 MG Y Healthcare Administered Drugs J9285 INJECTION OLARATUMAB 10 MG Y Healthcare Administered Drugs J9293 INJECTION MITOXANTRONE HCL PER 5 MG Y Healthcare Administered Drugs J9295 INJECTION NECITUMUMAB 1 MG Y Healthcare Administered Drugs J9299 INJECTION NIVOLUMAB 1 MG Y Healthcare Administered Drugs J9301 INJECTION OBINUTUZUMAB 10 MG Y Healthcare Administered Drugs J9302 INJECTION OFATUMUMAB 10 MG Y Healthcare Administered Drugs J9303 INJECTION PANITUMUMAB 10 MG Y Healthcare Administered Drugs J9304 INJECTION PEMETREXED (PEMFEXY) 10 MG Y Healthcare Administered Drugs J9305 INJECTION PEMETREXED 10 MG Y Healthcare Administered Drugs J9307 INJECTION PRALATREXATE 1 MG Y Healthcare Administered Drugs J9308 INJECTION RAMUCIRUMAB 5 MG Y Healthcare Administered Drugs J9309 Injection, polatuzumab vedotin-piiq, 1 mg Y Healthcare Administered Drugs J9311 INJECTION RITUXIMAB 10 MG AND HYALURONIDASE Y Healthcare Administered Drugs J9312 INJECTION RITUXIMAB 10 MG Y






Healthcare Administered Drugs J9313 INJECTION MOXETUMOMAB PASUDOTOX-TDFK 0.01 MG Y Healthcare Administered Drugs J9315 INJECTION ROMIDEPSIN 1 MG Y Healthcare Administered Drugs J9325 INJ TALIMOGENE LAHERPAREPVEC PER 1 M PLAQUE F U Y Healthcare Administered Drugs J9328 INJECTION TEMOZOLOMIDE 1 MG Y Healthcare Administered Drugs J9330 INJECTION TEMSIROLIMUS 1 MG Y Healthcare Administered Drugs J9340 INJECTION THIOTEPA 15 MG Y Healthcare Administered Drugs J9352 INJECTION TRABECTEDIN 0.1 MG Y Healthcare Administered Drugs J9354 INJ ADO-TRASTUZUMAB EMTANSINE 1 MG Y Healthcare Administered Drugs J9356 INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK Y Healthcare Administered Drugs J9357 INJECTION VALRUBICIN INTRAVESICAL 200 MG Y Healthcare Administered Drugs J9358 INJECTION, FAM-TRASTUZUMAB DERUXTECAN-NXKI, 1 mg Y Healthcare Administered Drugs J9371 INJECTION VINCRISTINE SULFATE LIPOSOME 1 MG Y Healthcare Administered Drugs J9395 INJECTION FULVESTRANT 25 MG Y Healthcare Administered Drugs J9400 INJECTION ZIV-AFLIBERCEPT 1 MG Y

Healthcare Administered Drugs J9600 INJECTION PORFIMER SODIUM 75 MG Y Mandatory review by Medical Director Healthcare Administered Drugs J9999 NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUG Y Healthcare Administered Drugs Q0138 INJ FERUMOXYTOL TX IRON DEF ANEMIA 1 MG NON-ESRD Y Healthcare Administered Drugs Q0139 INJ FERUMOXYTOL TX IRON DEF ANEMIA 1 MG FOR ESRD Y Healthcare Administered Drugs Q2043 SIPULEUCEL-T AUTO CD54 PLUS Y Healthcare Administered Drugs Q2050 INJECTION DOXORUBICIN HCL LIPOSOMAL NOS 10 MG Y Healthcare Administered Drugs Q3027 INJECTION INTERFERON BETA-1A 1 MCG IM USE Y Healthcare Administered Drugs Q3028 INJECTION INTERFERON BETA-1A 1 MCG SUBQ USE Y Healthcare Administered Drugs Q4074 ILOPROST INHAL SOL THRU DME UNIT DOSE TO 20 MCG Y Healthcare Administered Drugs Q5101 INJECTION FILGRASTIM BIOSIMILAR 1 MCG Y Healthcare Administered Drugs Q5103 INJECTION INFLIXIMAB-DYYB BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5104 INJECTION INFLIXIMAB-ABDA BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5105 Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on Y Healthcare Administered Drugs Q5106 Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD Y Healthcare Administered Drugs Q5107 INJECTION BEVACIZUMAB-AWWB BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5108 INJECTION PEGFILGRASTIM-JMDB BIOSIMILAR 0.5 MG Y Healthcare Administered Drugs Q5109 INJECTION INFLIXIMAB-QBTX BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5110 INJECTION FILGRASTIM-AAFI BIOSIMILAR 1 MCG Y Healthcare Administered Drugs Q5111 INJECTION PEGFILGRASTIM-CBQV BIOSIMILAR 0.5 MG Y Healthcare Administered Drugs Q5112 INJECTION TRASTUZUMAB-DTTB BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5113 INJECTION TRASTUZUMAB-PKRB BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5114 INJECTION TRASTUZUMAB-DKST BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5115 INJECTION RITUXIMAB-ABBS BIOSIMILAR 10 MG Y Healthcare Administered Drugs Q5116 INJECTION, TRASTUZUMAG-QYYP, BIOSIMILAR, (TRAZIMERA), 10 Y Healthcare Administered Drugs Q5117 INJECTION, TRASTUZUMAB-ANNS, BIOSIMILAR (kanjinti), 10 mg Y Healthcare Administered Drugs Q5118 INJECTION, BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG Y

Healthcare Administered Drugs Q5119 INJECTION, RITUXIMAB-PVVR, BIOSIMILAR, (ruxience), 10 mg Y

Healthcare Administered Drugs Q5120 INJECTION, PEGFILGRASTIM-BMEZ, BIOSIMILAR, (ziextenzo), 0.5 mg Y

Healthcare Administered Drugs Q5121 IJNECTION, INFLIXIMAB-AXXQ, BIOSIMILAR, (avsola), 10 mg Y

Healthcare Administered Drugs Q9991 INJECTION BUPRENORPHINE EXT-RLSE UNDER EQ TO 100 MG Y

Healthcare Administered Drugs Q9992 INJECTION BUPRENORPHINE EXTENDED-RELEASE OVER 100 MG Y Healthcare Administered Drugs S0073 INJECTION AZTREONAM 500 MG Y Healthcare Administered Drugs S0122 INJECTION MENOTROPINS 75 IU Y Healthcare Administered Drugs S0126 INJECTION FOLLITROPIN ALFA 75 IU Y Healthcare Administered Drugs S0128 INJECTION FOLLITROPIN BETA 75 IU Y Healthcare Administered Drugs S0132 INJECTION GANIRELIX ACETATE 250 MCG Y Healthcare Administered Drugs S0145 Injection, PEGylated interferon alfa-2A, 180 mcg per ml Y Healthcare Administered Drugs S0148 Injection, PEGylated interferon alfa-2B, 10 mcg Y Healthcare Administered Drugs S0157 BECAPLERMIN GEL 0.01PCT 0.5 GM Y

Home Health Care Services 99601 Home infusion/specialty drug administration, per visit (up to 2 hours);

Y Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech

Therapy. NOTE: Prior Authorization may be required for medications associated with HOME INFUSION therapy






Home Healt h Care Services 99602 Home infusion/specialt y dru g administration , pe r visi t (u p to 2 hours) ; ea ch additiona l hou r (Li st separatel y i n additio n to code for primar y procedure)

Y Y Home Healt h Service s require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech

Therapy. NOTE : Prio r Authorizatio n ma y be require d fo r medication s associate d with HOME INFUSIO N therapy

Home Health Care Services G0151 SERVICE PHYS THERAP HOME HLTH HOSPICE EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0152 SERVICE OCCUP THERAP HOME HLTH HOSPICE EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0153 SRVC SPCH AND LANG PATH HOME HLTH HOSPICE EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0155 SRVC CLINICAL SOCIAL WORKER HH HOSPICE EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0156 SRVC HH HOSPICE AIDE IN HH HOSPICE SET EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0157 SERVICES PT ASSIST HOME HEALTH HOSPICE EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0158 SERVICE OT ASSIST HOME HEALTH HOSPICE EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0159 SERVICES PT HOME HEALTH EST DEL PT MP EA 15 MINS Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0160 SERVICES OT HOME HEALTH EST DEL OT MP EA 15 MINS Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0161 SERVICE SLP HH EST DEL SPCH-LANG PATH MP EA 15 M Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0162 SKILLED SERVICE RN M AND E PLAN OF CARE; EA 15 MINS Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0299 DIRECT SNS RN HOME HEALTH HOSPICE SET EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0300 DIRECT SNS LPN HOME HLTH HOSPICE SET EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0493 SKILLED SERVICES RN OBV AND ASMT PT COND EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech


Home Health Care Services G0494 SKILLED SRVC LPN OBS AND ASMT PT COND EA 15 MIN Y Home Health Services require prior authorization after the initial evaluation/visit plus first six (6) visits, per calendar year, including for home based PT/OT and Speech







Home Healt h Care Services G0495 SKD SRV C RN TRAI N AND ED U P T FA M HH HOSP C E A 15 MI N Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services G0496 SKD SRV C LP N TRAI N AND EDU P T FA M HH HOSP C E 15 MI N Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services G0515 Developmen t o f cognitive skills to improve attention , memory , problem solvin g (includes compensator y training) , dire ct (one-on-one ) patien t contact , ea ch 15 minutes

Y Y Home Healt h Services require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services G9679 Onsite acute care treatmen t o f a nursin g facilit y residen t with pneumonia. Ma y onl y be bille d once pe r da y pe r beneficiary


Therapy. NOTE : Prio r Authorizatio n ma y be require d fo r medications associate d with HOME INFUSIO N therapy

Home Healt h Care Services G9680 Onsite acute care treatmen t o f a nursin g facilit y residen t wit h CHF. Ma y onl y be bille d once pe r da y pe r beneficiary



Home Healt h Care Services G9681 Onsite acute care treatmen t o f a nursin g facilit y residen t wit h COPD o r asthma. Ma y onl y be bille d once pe r da y pe r beneficiary

Y Y Home Healt h Services require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services G9682 Onsite acute care treatmen t o f a nursin g facilit y residen t wit h a skin infection. Ma y onl y be bille d once pe r da y pe r beneficiary

Y Y Home Healt h Service s require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services G9683 Facilit y service( s) fo r the onsite acute care treatmen t o f a nursin g facilit y residen t wit h flui d o r electrolyte disorder. (Ma y onl y be bille d once pe r da y pe r beneficiary. ) This service is fo r a demonstratio n project



Home Healt h Care Services G9684 Onsite acute care treatmen t o f a nursin g facilit y residen t fo r a UTI. Ma y onl y be bille d once pe r da y pe r beneficiary



Home Healt h Care Services S5102 Da y care service s, adult ; pe r diem Y Y Home Healt h Service s require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S5105 Da y care service s, center-based ; services no t include d i n program fee , pe r diem



Home Healt h Care Services S5116 Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S5125 Attendan t care services ; pe r 15 minutes Y Y Home Healt h Services require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S5130 HOMEMAKER SERVICE NOS ; PER 15 MINUTE S Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S5151 UNSKILLED RESPITE CARE NO T HOSPICE ; PER DIE M Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S9122 HO M HLTH AIDE CE RT NURSE ASS T PRO V CARE HOM;-HR Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech







Home Healt h Care Services S9123 NURSIN G CARE THE HOME ; REGISTERED NURSE PER HOUR Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S9124 NURSIN G CARE I N THE HOME ; BY LP N PER HOUR Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S9127 Socia l wor k visit , i n the home , pe r diem Y Y Home Healt h Service s require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S9128 SPEECH THERAPY I N THE HOME PER DIE M Y Home Healt h Services require prio r authorizatio n afte r the initia l evaluation/visi t plus firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S9129 OCCUPATIONA L THERAPY I N THE HOME PER DIE M Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S9131 PHYSICA L THERAPY ; I N THE HOME PER DIE M Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services S9379 Home infusio n therapy , infusio n therapy , no t otherwise classified ; administrative service s, professiona l pharma cy service s, care coordination , an d al l necessar y supplies an d equipmen t (drugs and nursin g visits code d separately) , pe r diem



Home Healt h Care Services S9470 NUTRITIONA L COUNSELIN G DIETITIA N VISI T Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services T1000 PRI V DUTY INDEPEND N RS SERVICE LI C U P 15 MI N Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services T1002 RN SERVICE S U P T O 15 MINUTE S Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services T1003 LP N LV N SERVICE S U P T O 15 MINUTE S Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services T1005 RESPITE CARE SERVICE S U P T O 15 MINUTE S Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services T1021 Home infusio n therapy , infusio n therapy , no t otherwise classified ; administrative service s, professiona l pharmacy service s, care coordination , an d al l necessar y supplies an d equipmen t (drugs and nursin g visits code d separately) , pe r diem

Y Y Home Healt h Services require prio r authorization afte r the initia l evaluation/visi t plus firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services T1022 CONTRAC T HOME HEALTH SRV C UNDER CONTRAC T DAY Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visits , pe r calenda r year , includin g fo r home base d PT/O T an d Speech


Home Healt h Care Services T1030 NURSIN G CARE THE HOME REGISTERED NURSE PER DIE M Y Home Healt h Service s require prio r authorizatio n afte r the initia l evaluation/visi t plu s firs t si x (6 ) visit s, pe r calenda r year , includin g fo r home base d PT/O T an d Speech





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48



Imaging & Special Tests 70498 CT ANGIOGRAPHY NECK W CONTRAST NONCONTRAST Y Imaging & Special Tests 70540 MRI ORBIT FACE AND NECK W O CONTRAST Y Imaging & Special Tests 70542 MRI ORBIT FACE AND NECK W CONTRAST MATERIAL Y Imaging & Special Tests 70543 MRI ORBIT FACE AND NECK W O AND W CONTRAST MATRL Y Imaging & Special Tests 70544 MRA HEAD W O CONTRST MATERIAL Y Imaging & Special Tests 70545 MRA HEAD W CONTRAST MATERIAL Y Imaging & Special Tests 70546 MRA HEAD W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 70547 MRA NECK W O CONTRST MATERIAL Y Imaging & Special Tests 70548 MRA NECK W CONTRAST MATERIAL Y Imaging & Special Tests 70549 MRA NECK W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 70551 MRI BRAIN BRAIN STEM W O CONTRAST MATERIAL Y Imaging & Special Tests 70552 MRI BRAIN BRAIN STEM W CONTRAST MATERIAL Y Imaging & Special Tests 70553 MRI BRAIN BRAIN STEM W O W CONTRAST MATERIAL Y Imaging & Special Tests 70554 MRI BRAIN FUNCTIONAL W O PHYSICIAN ADMNISTRATION Y Imaging & Special Tests 70555 MRI BRAIN FUNCTIONAL W PHYSICIAN ADMNISTRATION Y Imaging & Special Tests 71250 CT THORAX W O CONTRAST MATERIAL Y Imaging & Special Tests 71260 CT THORAX W CONTRAST MATERIAL Y Imaging & Special Tests 71270 CT THORAX W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 71275 CT ANGIOGRAPHY CHEST W CONTRAST NONCONTRAST Y Imaging & Special Tests 71550 MRI CHEST W O CONTRAST MATERIAL Y Imaging & Special Tests 71551 MRI CHEST W CONTRAST MATERIAL Y Imaging & Special Tests 71552 MRI CHEST W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 71555 MRA CHEST W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 72125 CT CERVICAL SPINE W O CONTRAST MATERIAL Y Imaging & Special Tests 72126 CT CERVICAL SPINE W CONTRAST MATERIAL Y Imaging & Special Tests 72127 CT CERVICAL SPINE W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 72128 CT THORACIC SPINE W O CONTRAST MATERIAL Y Imaging & Special Tests 72129 CT THORACIC SPINE W CONTRAST MATERIAL Y Imaging & Special Tests 72130 CT THORACIC SPINE W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 72131 CT LUMBAR SPINE W O CONTRAST MATERIAL Y Imaging & Special Tests 72132 CT LUMBAR SPINE W CONTRAST MATERIAL Y Imaging & Special Tests 72133 CT LUMBAR SPINE W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 72141 MRI SPINAL CANAL CERVICAL W O CONTRAST MATRL Y Imaging & Special Tests 72142 MRI SPINAL CANAL CERVICAL W CONTRAST MATRL Y Imaging & Special Tests 72146 MRI SPINAL CANAL THORACIC W O CONTRAST MATRL Y Imaging & Special Tests 72147 MRI SPINAL CANAL THORACIC W CONTRAST MATRL Y Imaging & Special Tests 72148 MRI SPINAL CANAL LUMBAR W O CONTRAST MATERIAL Y Imaging & Special Tests 72149 MRI SPINAL CANAL LUMBAR W CONTRAST MATERIAL Y Imaging & Special Tests 72156 MRI SPINAL CANAL CERVICAL W O AND W CONTR MATRL Y Imaging & Special Tests 72157 MRI SPINAL CANAL THORACIC W O AND W CONTR MATRL Y Imaging & Special Tests 72158 MRI SPINAL CANAL LUMBAR W O AND W CONTR MATRL Y Imaging & Special Tests 72159 MRA SPINAL CANAL W WO CONTRAST MATERIAL Y Imaging & Special Tests 72191 CT ANGIOGRAPHY PELVIS W CONTRAST NONCONTRAST Y Imaging & Special Tests 72192 CT PELVIS W O CONTRAST MATERIAL Y Imaging & Special Tests 72193 CT PELVIS W CONTRAST MATERIAL Y Imaging & Special Tests 72194 CT PELVIS W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 72195 MRI PELVIS W O CONTRAST MATERIAL Y Imaging & Special Tests 72196 MRI PELVIS W CONTRAST MATERIAL Y Imaging & Special Tests 72197 MRI PELVIS W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 72198 MRA PELVIS W WO CONTRAST MATERIAL Y Imaging & Special Tests 73200 CT UPPER EXTREMITY W O CONTRAST MATERIAL Y Imaging & Special Tests 73201 CT UPPER EXTREMITY W CONTRAST MATERIAL Y Imaging & Special Tests 73202 CT UPPER EXTREMITY W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 73206 CT ANGIOGRAPHY UPPER EXTREMITY Y Imaging & Special Tests 73218 MRI UPPER EXTREMITY OTH THAN JT W O CONTR MATRL Y Imaging & Special Tests 73219 MRI UPPER EXTREMITY OTH THAN JT W CONTR MATRL Y Imaging & Special Tests 73220 MRI UPPER EXTREM OTHER THAN JT W O AND W CONTRAS Y Imaging & Special Tests 73221 MRI ANY JT UPPER EXTREMITY W O CONTRAST MATRL Y Imaging & Special Tests 73222 MRI ANY JT UPPER EXTREMITY W CONTRAST MATRL Y Imaging & Special Tests 73223 MRI ANY JT UPPER EXTREMITY W O AND W CONTR MATRL Y Imaging & Special Tests 73225 MRA UPPER EXTREMITY W WO CONTRAST MATERIAL Y Imaging & Special Tests 73700 CT LOWER EXTREMITY W O CONTRAST MATERIAL Y Imaging & Special Tests 73701 CT LOWER EXTREMITY W CONTRAST MATERIAL Y Imaging & Special Tests 73702 CT LOWER EXTREMITY W O AND W CONTRAST MATRL Y Imaging & Special Tests 73706 CT ANGIOGRAPHY LOWER EXTREMITY Y






Imaging & Special Tests 73718 MRI LOWER EXTREM OTH THN JT W O CONTR MATRL Y Imaging & Special Tests 73719 MRI LOWER EXTREM OTH THN JT W CONTRAST MATRL Y Imaging & Special Tests 73720 MRI LOWER EXTREM OTH THN JT W O AND W CONTR MATR Y Imaging & Special Tests 73721 MRI ANY JT LOWER EXTREM W O CONTRAST MATRL Y Imaging & Special Tests 73722 MRI ANY JT LOWER EXTREM W CONTRAST MATERIAL Y Imaging & Special Tests 73723 MRI ANY JT LOWER EXTREM W O AND W CONTRAST MATRL Y Imaging & Special Tests 73725 MRA LOWER EXTREMITY W WO CONTRAST MATERIAL Y Imaging & Special Tests 74150 CT ABDOMEN W O CONTRAST MATERIAL Y Imaging & Special Tests 74160 CT ABDOMEN W CONTRAST MATERIAL Y Imaging & Special Tests 74170 CT ABDOMEN W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 74174 CT ANGIO ABD AND PLVIS CNTRST MTRL W WO CNTRST IMG Y Imaging & Special Tests 74175 CT ANGIOGRAPHY ABDOMEN W CONTRAST NONCONTRAST Y

Imaging & Special Tests 74176 CT ABDOMEN AND PELVIS W O CONTRAST MATERIAL Y

Imaging & Special Tests 74177 CT ABDOMEN AND PELVIS W CONTRAST MATERIAL Y

Imaging & Special Tests 74178 CT ABDOMEN AND PELVIS W O CONTRST 1 OR GRT BODY RE Y

Imaging & Special Tests 74181 MRI ABDOMEN W O CONTRAST MATERIAL Y

Imaging & Special Tests 74182 MRI ABDOMEN W CONTRAST MATERIAL Y

Imaging & Special Tests 74183 MRI ABDOMEN W O AND W CONTRAST MATERIAL Y Imaging & Special Tests 74185 MRA ABDOMEN W WO CONTRAST MATERIAL Y Imaging & Special Tests 74261 CT COLONOGRPHY DX IMAGE POSTPROCESS W O CONTRAST Y Imaging & Special Tests 74262 CT COLONOGRPHY DX IMAGE POSTPROCESS W CONTRAST Y Imaging & Special Tests 74263 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING Y Imaging & Special Tests 74712 FETAL MRI W PLACNTL MATRNL PLVC IMG SING 1ST GES Y Imaging & Special Tests 75557 CARDIAC MRI MORPHOLOGY AND FUNCTION W O CONTRAST Y Imaging & Special Tests 75559 CARDIAC MRI W O CONTRAST W STRESS IMAGING Y Imaging & Special Tests 75561 CARDIAC MRI W WO CONTRAST AND FURTHER SEQ Y Imaging & Special Tests 75563 CARDIAC MRI W W O CONTRAST W STRESS Y Imaging & Special Tests 75571 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM Y Imaging & Special Tests 75572 CT HEART CONTRAST EVAL CARDIAC STRUCTURE AND MORPH Y Imaging & Special Tests 75573 CT HRT CONTRST CARDIAC STRUCT AND MORPH CONG HRT D Y Imaging & Special Tests 75574 CTA HRT CORNRY ART BYPASS GRFTS CONTRST 3D POST Y Imaging & Special Tests 75635 CTA ABDL AORTA AND BI ILIOFEM W CONTRAST AND POSTP Y Imaging & Special Tests 76376 3D RENDERING W INTERP AND POSTPROCESS SUPERVISION Y






Imaging & Special Tests 76377 3D RENDERING W INTERP AND POSTPROC DIFF WORK STATION Y Imaging & Special Tests 76380 CT LIMITED LOCALIZED FOLLOW UP STUDY Y Imaging & Special Tests 76390 MRI SPECTROSCOPY Y Imaging & Special Tests 76497 UNLISTED COMPUTED TOMOGRAPHY PROCEDURE Y Imaging & Special Tests 76498 UNLISTED MAGNETIC RESONANCE PROCEDURE Y Imaging & Special Tests 76999 UNLISTED US PROCEDURE Y Imaging & Special Tests 77046 MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL Y Imaging & Special Tests 77047 MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL Y Imaging & Special Tests 77048 MRI BREAST W OUT AND WITH CONTRAST W CAD UNILATERAL Y Imaging & Special Tests 77049 MRI BREAST WITHOUT AND WITH CONTRAST W CAD BILATERAL Y Imaging & Special Tests 77084 BONE MARROW BLOOD SUPPLY Y Imaging & Special Tests 78300 Bone and/or joint imaging; limited area Y Imaging & Special Tests 78305 Bone and/or joint imaging; multiple areas Y Imaging & Special Tests 78306 Bone and/or joint imaging; whole body Y Imaging & Special Tests 78315 Bone and/or joint imaging; 3 phase study Y Imaging & Special Tests 78429 Myocardial imaging, positron emission tomography (PET), Y Imaging & Special Tests 78430 Myocardial imaging, positron emission tomography (PET), perfusion Y Imaging & Special Tests 78431 Myocardial imaging, positron emission tomography (PET), perfusion Y Imaging & Special Tests 78432 Myocardial imaging, positron emission tomography (PET), Y Imaging & Special Tests 78433 Myocardial imaging, positron emission tomography (PET), Y Imaging & Special Tests 78451 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS Y Imaging & Special Tests 78452 MYOCARDIAL SPECT MULTIPLE STUDIES Y Imaging & Special Tests 78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST STRESS Y

Imaging & Special Tests 78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES Y Imaging & Special Tests 78459 MYOCARDIAL IMAGING PET METABOLIC EVALUATION Y Imaging & Special Tests 78466 MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL QUAN Y Imaging & Special Tests 78468 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ Y Imaging & Special Tests 78469 MYOCRD INFARCT AVID PLNR TOMOG SPECT W WO QUANTJ Y Imaging & Special Tests 78472 CARD BLOOD POOL GATED PLANAR 1 STUDY REST STRESS Y Imaging & Special Tests 78473 CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT Y Imaging & Special Tests 78481 CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT Y

Imaging & Special Tests 78483 CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT Y

Imaging & Special Tests 78491 MYOCRD IMAGE PET PERFUS SINGLE STUDY REST STRESS Y Imaging & Special Tests 78492 MYOCRD IMAGE PET PERFUS MULTPL STUDY REST STRESS Y Imaging & Special Tests 78494 CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT Y Imaging & Special Tests 78499 UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE Y Imaging & Special Tests 78608 BRAIN IMAGING PET METABOLIC EVALUATION Y Imaging & Special Tests 78609 BRAIN IMAGING PET PERFUSION EVALUATION Y Imaging & Special Tests 78800 Radiopharmaceutical localization of tumor, inflammatory process Y Imaging & Special Tests 78801 Radiopharmaceutical localization of tumor, inflammatory process Y Imaging & Special Tests 78802 Radiopharmaceutical localization of tumor, inflammatory process Y Imaging & Special Tests 78803 Radiopharmaceutical localization of tumor or distribution of Y Imaging & Special Tests 78811 PET IMAGING LIMITED AREA CHEST HEAD NECK Y Imaging & Special Tests 78812 PET IMAGING SKULL BASE TO MID-THIGH Y Imaging & Special Tests 78813 PET IMAGING WHOLE BODY Y Imaging & Special Tests 78814 PET IMAGING CT FOR ATTENUATION LIMITED AREA Y Imaging & Special Tests 78815 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH Y Imaging & Special Tests 78816 PET IMAGING FOR CT ATTENUATION WHOLE BODY Y Imaging & Special Tests 78830 Radiopharmaceutical localization of tumor, inflammatory process Y Imaging & Special Tests 78831 Radiopharmaceutical localization of tumor, inflammatory process Y Imaging & Special Tests 78832 Radiopharmaceutical localization of tumor, inflammatory process Y Imaging & Special Tests 93998 UNLISTED NONINVASIVE VASCULAR DIAGNOSTIC STUDY Y

Imaging & Special Tests 0042T CEREBRAL PERFUSION ANALYS CT W BLOOD FLOW AND VOLUME Y Imaging & Special Tests 0331T MYOCRD SYMPATHETIC INNERVAJ IMG PLNR QUAL AND QUANT Y Imaging & Special Tests 0332T MYOCRD SYMP INNERVAJ IMG PLNR QUAL AND QUANT W SPECT Y Imaging & Special Tests 0501T COR FFR DERIVED CTA DATA ASSESS COR ART DISEASE Y Imaging & Special Tests 0502T COR FFR DERIVED CTA DATA PREP AND TRANSMIS Y Imaging & Special Tests 0503T COR FFR CTA DATA ALYS AND GNRJ ESTIMATED FFR MODEL Y Imaging & Special Tests 0504T COR FFR CTA DATA REVIEW W INTERPJ AND FINAL REPORT Y Imaging & Special Tests C8900 MR ANGIOGRAPHY WITH CONTRAST ABDOMEN Y Imaging & Special Tests C8901 MR ANGIOGRAPHY WITHOUT CONTRAST ABDOMEN Y






Imaging & Special Tests C8902 MR ANGIO WITHOUT CONTRST FOLLOWED W CONTRST ABD Y Imaging & Special Tests C8903 MR IMAGING WITH CONTRAST BREAST; UNILATERAL Y Imaging & Special Tests C8905 MR IMAG W O CONTRST FLWED W CONTRST BRST; UNI Y Imaging & Special Tests C8906 MR IMAGING WITH CONTRAST BREAST; BILATERAL Y Imaging & Special Tests C8908 MR IMAG W O CONTRST FLWED W CONTRST BRST; BIL Y Imaging & Special Tests C8909 MR ANGIOGRAPHY WITH CONTRAST CHEST Y Imaging & Special Tests C8910 MR ANGIOGRAPHY WITHOUT CONTRAST CHEST Y Imaging & Special Tests C8911 MR ANGIO WITHOUT CONTRST FOLLOWED W CONTRST CHST Y Imaging & Special Tests C8912 MR ANGIOGRAPHY WITH CONTRAST LOWER EXTREMITY Y Imaging & Special Tests C8913 MR ANGIOGRAPHY WITHOUT CONTRAST LOWER EXTREMITY Y Imaging & Special Tests C8914 MR ANGIO W O CONTRST FLWED W CONTRST LOW EXTRM Y Imaging & Special Tests C8918 MR ANGIOGRAPHY WITH CONTRAST PELVIS Y Imaging & Special Tests C8919 MR ANGIOGRAPHY WITHOUT CONTRAST PELVIS Y Imaging & Special Tests C8920 MRA WITHOUT CONTRAST FOLLOWED W CONTRAST PELVIS Y Imaging & Special Tests C8931 MR ANGIOGRAPHY W CONTRAST SPINAL CANAL CONTENTS Y Imaging & Special Tests C8932 MR ANGIOGRAPHY W O CONTRST SPINAL CANAL CONTENTS Y Imaging & Special Tests C8933 MR ANGIO NO CONTRST FLW W CONTRST SP CANAL CNTN Y Imaging & Special Tests C8934 MR ANGIOGRAPHY WITH CONTRAST UPPER EXTREMITY Y Imaging & Special Tests C8935 MR ANGIOGRAPHY WITHOUT CONTRAST UPPER EXTREMITY Y Imaging & Special Tests C8936 MR ANGIO W O CONTRST FOLLOWED W CONTRST UP EXT Y Imaging & Special Tests G0219 PET IMAG WHOLE BODY; MELANOMA NON-COVR INDICATS Y Imaging & Special Tests G0235 PET IMAGING ANY SITE NOT OTHERWISE SPECIFIED Y Imaging & Special Tests G0252 PET IMAG INIT DX BREST CA AND SURG PLAN NOT COV MCR Y Imaging & Special Tests G0297 LOW DOSE CT SCAN FOR LUNG CANCER SCREENING Y Imaging & Special Tests S8042 MAGNETIC RESONANCE IMAGING LOW-FIELD Y

Neuropsychologica l an d Psychological Tests [I n an y Setting]

95700 ELECTROENCEPHALOGRA M (EEG ) CONTINUOU S RECORDING. WITH VIDE O WHE N PERFORMED , SETUP , PATIEN T EDUCATION , AND TAKEDOW N WHE N PERFORMED , ADMINISTERED I N PERSO N BY EE G TECHNOLOGIST , MINIMU M O F 8 CHANNELS

Y


95708 Electroencephalogram (EEG) , withou t video , revie w o f data , technica l descriptio n b y EE G technologist , ea ch incremen t o f 12-2 6 hours ; unmonitored

Y


95709 Electroencephalogram (EEG) , withou t video , revie w o f data , technica l descriptio n b y EE G technologist , ea ch incremen t o f 12-2 6 hours ; wit h intermitten t monitorin g an d maintenance

Y


95710 Electroencephalogram (EEG) , withou t video , revie w o f data , technica l descriptio n b y EE G technologist , ea ch incremen t o f 12-2 6 hours ; wit h continuou s, real-time monitorin g an d maintenance

Y

Neuropsychologica l an d Psychological Test s [I n an y Setting]

95711 Electroencephalogram wit h video (VEEG) , revie w o f data , technical descriptio n b y EE G technologist , 2-1 2 hour s; unmonitored

Y


95712 Electroencephalogram wit h video (VEEG) , revie w o f data , technical descriptio n b y EE G technologist , 2-1 2 hour s; wit h intermitten t monitorin g an d maintenance

Y


95713 Electroencephalogram wit h video (VEEG) , revie w o f data , technical descriptio n b y EE G technologist , 2-12 hour s; wit h continuou s, real-time monitorin g an d maintenance

Y


95714 Electroencephalogram wit h video (VEEG) , revie w o f data , technical descriptio n b y EE G technologist , ea ch incremen t o f 12-2 6 hour s; unmonitored

Y


95715 Electroencephalogram wit h video (VEEG) , revie w o f data , technical descriptio n b y EE G technologist , ea ch incremen t o f 12-2 6 hour s; wit h intermitten t monitorin g an d maintenance

Y


95716 Electroencephalogram wit h video (VEEG) , revie w o f data , technical descriptio n b y EE G technologist , ea ch incremen t o f 12-2 6 hour s; wit h continuou s, real-time monitorin g an d maintenance

Y


95718 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , interpretatio n an d report , 2-12 hour s o f EE G recording ; wit h video (VEEG)

Y







95719 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , ea ch incremen t o f greater tha n 12 hour s, u p to 26 hour s o f EE G recording , interpretatio n and repor t afte r ea ch 24-hou r period ; withou t video

Y


95720 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , ea ch incremen t o f greater tha n 12 hour s, u p to 26 hour s o f EE G recording , interpretatio n and repor t afte r ea ch 24-hou r period ; wit h video (VEEG)

Y


95721 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , interpretation , and summar y report , complete study ; greate r tha n 36 hours , u p to 60 hour s o f EE G recording , withou t video

Y


95722 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , interpretation , and summar y report , complete study ; greate r tha n 36 hours , u p to 60 hour s o f EE G recording , wit h video (VEEG)

Y


95723 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , interpretation , and summar y report , complete study ; greate r tha n 60 hours , u p to 84 hour s o f EE G recording , withou t video

Y


95724 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , interpretation , and summar y report , complete study ; greate r tha n 60 hours , u p to 84 hour s o f EE G recording , wit h video (VEEG)

Y


95725 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysi s o f spike an d seizure detection , interpretation , and summar y report , complete study ; greate r tha n 84 hour s o f EE G recording , withou t video

Y


95726 Electroencephalogram (EEG) , continuou s recording , physicia n or othe r qualifie d healt h care professiona l revie w o f recorde d events , analysis o f spike an d seizure detection , interpretation , and summar y report , complete study ; greate r tha n 84 hours o f EE G recording , wit h video (VEEG)

Y


95957 DIGITA L ANALYSI S ELECTROENCEPHALOGRA M Y


96105 Assessmen t o f aphasi a (includes assessmen t o f expressive and receptive spee ch an d language function , language comprehension , spee ch productio n ability , reading , spelling , writing , eg , b y Boston Diagnosti c Aphasi a Examination ) wit h interpretatio n an d report , pe r hour

Y Y


96110 Developmenta l screenin g (eg , developmenta l milestone survey , spee ch an d language dela y screen) , wit h scorin g and documentation , pe r standardize d instrument

Y Y


96112 DEVELOPMENTA L TS T ADMI N PHY S QH P 1S T HOUR Y


96113 DEVELOPMENTA L TS T ADMI N PHY S QH P E A ADD L 30 MI N Y


96116 NEUROBEHAVIORA L STATU S X M PHY S QH P 1S T HOUR Y


96121 NEUROBEHAVIORA L STATU S X M PHY S QH P E A ADD L HOUR Y







96125 STANDARDIZED COGNITIVE PERFORMANCE TESTIN G Y


96130 PSYCHOLOGICA L TS T EVA L SV C PHY S QH P FIRS T HOUR Y


96131 PSYCHOLOGICA L TS T EVA L SV C PHY S QH P E A ADD L HOUR Y


96132 NEUROPSYCHOLOGICA L TS T EVA L PHY S QH P 1S T HOUR Y


96133 NEUROPSYCHOLOGICA L TS T EVA L PHY S QH P E A ADD L HR Y


96136 PSY L NRPSYC L TS T PHY S QH P 2 PLU S TS T 1S T 30 MI N Y


96137 PSYC L NRPSYC L TS T PHY S QH P 2 PLU S TS T E A ADD L 30 MI N Y


96138 PSYC L NRPSYC L TS T TECH 2 PLU S TS T 1S T 30 MI N Y


96139 PSYC L NRPSYC L TS T TECH 2 PLU S TS T E A ADD L 30 MIN Y

Neuropsychologica l an d Psychological Tests [I n an y Setting] Occupationa l Therapy

96146 PSYC L NRPSYC L TS T ELE C PLATFO RM AUT O RESUL T Y

97010 Applicatio n o f a modalit y to 1 o r more area s; ho t o r col d packs Y Y Age s 18 and younge r require prio r authorizatio n afte r the initia l evaluation/visi t plus the firs t si x (6 ) visit s fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior

authorizatio n fo r Occupationa l Therapy. I n Sout h Carolina , 9711 2 i s no t reimbursable to Occupationa l Therap y Providers. Prio r Authorizatio n request s wit h a n Occupational

Therapis t a s the servicin g provide r wil l be denie d fo r 97112.

Occupationa l Therapy 97012 Applicatio n o f a modalit y to 1 o r more area s; traction , mechanical Y Y Age s 1 8 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plu s the firs t si x (6 ) visit s fo r Outpatien t settings. Age s 19 an d ove r do NO T require prior



Occupationa l Therapy 97014 Applicatio n o f a modalit y to 1 o r more area s; electrica l stimulation (unattended)

Y Y Age s 1 8 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plu s the firs t si x (6 ) visit s fo r Outpatien t settings. Age s 1 9 an d ove r do NO T require prior



Occupationa l Therapy 97016 Applicatio n o f a modalit y to 1 o r more area s; vasopneumati c devices

Y Y Age s 1 8 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plu s the firs t si x (6 ) visit s fo r Outpatien t settings. Age s 1 9 an d ove r do NO T require prior



Occupationa l Therapy 97018 Applicatio n o f a modalit y to 1 o r more area s; paraffi n bath Y Y Age s 1 8 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plu s the firs t si x (6 ) visit s fo r Outpatien t settings. Age s 1 9 an d ove r do NO T require prior

authorizatio n fo r Occupationa l Therapy . I n Sout h Carolina , 9711 2 i s no t reimbursabl e to Occupationa l Therap y Providers. Prio r Authorizatio n request s wit h a n Occupational


Occupationa l Therapy 97022 Applicatio n o f a modalit y to 1 o r mor e area s; whirlpool Y Y Age s 1 8 an d younger requir e prio r authorizatio n afte r th e initia l evaluation/visi t plu s th e firs t si x (6 ) visit s fo r Outpatien t settings. Age s 1 9 an d ove r do NO T require prior

authorizatio n fo r Occupationa l Therapy . I n Sout h Carolina , 9711 2 i s no t reimbursabl e t o Occupationa l Therap y Provider s. Prio r Authorizatio n request s wit h a n Occupational

Therapis t a s th e servicin g provide r wil l b e denie d fo r 97112 .

Occupationa l Therapy 97024 Applicatio n o f a modalit y t o 1 o r mor e area s; diatherm y (eg , microwave)

Y Y Age s 1 8 an d younge r requir e prio r authorizatio n afte r th e initia l evaluation/visi t plu s th e firs t si x (6 ) visit s fo r Outpatien t setting s. Age s 1 9 an d ove r do NO T requir e prior

authorizatio n fo r Occupationa l Therapy . I n Sout h Carolina , 9711 2 i s no t reimbursabl e t o Occupationa l Therap y Provider s. Prio r Authorizatio n request s wit h a n Occupationa l

Therapis t a s th e servicin g provide r wil l b e denie d fo r 97112 .






Occupationa l Therapy 97026 Applicatio n o f a modalit y to 1 o r more area s; infrared Y Y Age s 1 8 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plu s the firs t si x (6 ) visit s fo r Outpatien t settings. Age s 19 an d ove r do NO T require prior



Occupational Therapy 97028 Application of a modality to 1 or more areas; ultraviolet Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the first six (6) visits for Outpatient settings. Ages 19 and over do NOT require prior

authorization for Occupational Therapy. In South Carolina, 97112 is not reimbursable to Occupational Therapy Providers. Prior Authorization requests with an Occupational

Therapist as the servicing provider will be denied for 97112.

Occupational Therapy 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the first six (6) visits for Outpatient settings. Ages 19 and over do NOT require prior



Occupational Therapy 97033 Application of a modality to 1 or more areas; iontophoresis, each 15 minutes




Occupational Therapy 97034 Application of a modality to 1 or more areas; contrast baths, each 15 minutes




Occupational Therapy 97035 Application of a modality to 1 or more areas; ultrasound, each 15 minutes




Occupational Therapy 97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes




Occupational Therapy 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the first six (6) visits for Outpatient settings. Ages 19 and over do NOT require prior



Occupational Therapy 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises




Occupational Therapy 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)







Matrix Service Category Code DefinitionSC P A


Occupationa l Therapy 97124 Therapeuti c procedure , 1 o r more area s, ea ch 15 minutes ; massage , includin g effleurage , petrissage and/o r tapotemen t (stroking , compression , percussion)

Y Y Age s 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plus the firs t si x (6 ) visit s fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior



Occupational Therapy 97129 Therapeuti c interventions tha t focu s o n cognitive functio n (eg , attention , memory , reasoning , executive function , problem solving , and/o r pragmatic functioning ) an d compensator y strategies to manage the performance o f a n activit y (eg , managin g time or schedules , initiating , organizing , an d sequencin g tasks) , dire ct (one-on-one ) patien t contact ; initia l 15 minutes




Occupational Therapy 97130 Therapeuti c intervention s tha t focu s o n cognitive functio n (eg , attention , memory , reasoning , executive function , problem solving , and/o r pragmati c functioning ) an d compensator y strategie s to manage the performance o f a n activit y (eg , managin g time or schedules , initiating , organizing , an d sequencin g tasks) , dire ct (one-on-one ) patien t contact ; ea ch additiona l 1 5 minute s (Li st separatel y i n additio n to code fo r primar y procedure)




Occupational Therapy 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes




Occupational Therapy 97150 Therapeutic procedure(s), group (2 or more individuals) Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the first six (6) visits for Outpatient settings. Ages 19 and over do NOT require prior



Occupational Therapy 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes




Occupational Therapy 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes




Occupational Therapy 97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes




Occupational Therapy 97537 Community/wor k reintegratio n trainin g (eg , shopping , transportation , mone y management , avocationa l activitie s and/or wor k environment/modificatio n analysis , wor k tas k analysi s, use o f assistive technolog y device/adaptive equipment) , dire ct one-on-one contact , ea ch 1 5 minutes




Occupational Therapy 97542 Wheelchair management (eg, assessment, fitting, training), each 15 minutes









Occupationa l Therapy 97760 Orthotic(s ) managemen t an d trainin g (includin g assessmen t and fittin g whe n no t otherwise reported) , uppe r extremity(ies) , lower extremity(ie s) and/o r trunk , initia l orthotic( s) encounter , ea ch 15 minutes

Y Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plus the firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior

authorizatio n fo r Occupationa l Therapy. I n Sout h Carolina , 97112 i s no t reimbursable to Occupationa l Therap y Providers. Prio r Authorizatio n requests wit h a n Occupational

Therapis t as the servicin g provide r wil l be denie d fo r 97112.

Occupationa l Therapy 97761 Prosthetic(s ) training , uppe r and/o r lowe r extremity(ies) , initial prosthetic( s) encounter , ea ch 15 minutes

Y Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visit plus the firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior

authorizatio n fo r Occupationa l Therapy. I n Sout h Carolina , 97112 is no t reimbursable to Occupationa l Therap y Providers. Prio r Authorizatio n requests wit h a n Occupational

Therapis t as the servicin g provide r wil l be denie d fo r 97112.

Occupationa l Therapy 97763 Orthotic(s)/prosthetic( s) managemen t and/o r training , upper extremity(ies) , lowe r extremity(ies) , and/o r trunk , subsequen t orthotic(s)/prosthetic( s) encounter , ea ch 15 minutes

Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plus the firs t si x (6 ) visit s fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior



Out-Patien t Hospital/Ambulator y Surger y Cente r (ASC ) Procedures

10040 ACNE SURGERY Y


15769 Graftin g o f autologous sof t tissue , other , harveste d b y dire ct excisio n (eg , fat , dermi s, fascia)

Y

Out-Patien t Hospital/Ambulator y Surgery Cente r (ASC ) Procedures

15771 Graftin g o f autologous fa t harveste d b y liposuctio n technique to trunk , breasts , scalp , arms , and/o r leg s; 50 cc o r less injectate

Y


15773 Graftin g o f autologous fa t harveste d b y liposuctio n technique to face , eyelids , mouth , neck , ears , orbit s, genitalia , hand s, and/or

Y


15786 ABRASIO N 1 LESIO N Y


15819 CERVICOPLASTY Y


15830 EXCISIO N SKI N ABD INFRAUMBILICA L PANNICULECTOMY

Y


17004 DESTRUCTIO N PREMALIGNAN T LESIO N 15 OR G RT Y


17360 CHEMICA L EXFOLIATIO N ACNE Y


20560 Needle insertion( s) withou t injection(s) ; 1 o r 2 muscle(s) Y


20561 Needle insertion( s) withou t injection(s) ; 3 o r more muscles Y


21073 MANIPULATIO N TM J THERAPEUTI C REQUIRE ANESTHESI A

Y


21120 GENIOPLASTY AUGMENTATIO N Y


21121 GENIOPLASTY SLIDIN G OSTEOTOMY SINGLE PIECE

Y


21122 GENIOPLASTY 2 OR G RT SLIDIN G OSTEOTOMIE S Y


21123 GENIO P SLIDIN G AGMNT J W INTERPOSA L BONE GRAFT S Y


21125 AGMNT J MNDBLR BODY ANGLE PROSTHETI C MATERIA L Y


21127 AGMNT J MNDBLR BDY ANG L W G RF ONLAY INTERPOSAL Y


21137 REDUCTIO N FOREHEAD CONTOURIN G ONLY Y


21138 RDCT J FHD CNT RG AND PROSTHETI C MAT RL BONE GRAFT Y







21139 RDCT J FHD CNT RG AND SETBAC K AN T FRONTA L SINU S WAL L

Y


21141 RCNST J MIDFACE LEFO RT I 1 PIECE W O BONE GRAF T

Y


21142 RCNST J MIDFACE LEFO RT I 2 PIECE S W O BONE GRAF T Y


21143 RCNST J MIDFACE LEFO RT I 3 OR G RT PIECE W O BONE GRAF T Y


21145 RCNST J MIDFACE LEFO RT I 1 PIECE W BONE GRAFT S

Y


21146 RCNST J MIDFACE LEFO RT I 2 PIECE S W BONE GRAFTS Y


21147 RCNST J MIDFACE LEFO RT I 3 OR G RT PIECE W BONE GRAFT S Y


21150 RCNST J MIDFACE LEFO RT II ANTERIOR INTRUSIO N

Y


21151 RCNST J MIDFACE LEFO RT II W BONE GRAFTS Y


21154 RCNST J MIDFACE LEFO RT III W O LEFO RT I Y


21155 RCNST J MIDFACE LEFO RT III W LEFO RT I Y


21159 RCNST J MIDFACE LEFO RT III W FHD W O LEFO RT I Y


21160 RCNST J MIDFACE LEFO RT III W FHD W LEFO RT I Y


21172 RCNST J SUPERIOR-LATERA L ORBITA L RI M AND LOWER FHD Y


21175 RCNST J BIFRONTA L SUPERIOR-LA T ORB RIM S AND LWR FHD Y


21240 ARTH RP TEMPOROMANDIBULAR JOIN T W W O AUTOGRAF T Y


21242 ARTHROPLASTY TEMPOROMANDIBULAR J T W ALLOGRAF T Y


21243 ARTH RP TMPRMAND JOIN T W PROSTHETI C REPLACEMEN T Y


21270 MALAR AUGMENTATIO N PROSTHETI C MATERIAL Y


21280 MEDIA L CANTHOPEXY SEPARATE PROCEDURE Y

Out-Patien t Hospital/AmbulatorySurger y Cente r (ASC ) Procedures

21282 LATERA L CANTHOPEXY Y


21295 REDUCTIO N MASSETER MUSCLE AND BONE EXTRAORA L Y


21296 REDUCTIO N MASSETER MUSCLE AND BONE INTRAORA L Y


21601 Excisio n o f che st wal l tumo r includin g rib(s) Y


21602 Excisio n o f che st wal l tumo r involvin g rib(s) , wit h plasti c reconstruction ; withou t mediastina l lymphadenectomy

Y


21603 Excisio n o f che st wal l tumo r involvin g rib(s) , wit h plasti c reconstruction ; wit h mediastina l lymphadenectomy

Y


22100 PRT L EX C PS T V RT INTRNS C B1Y LE S 1 V RT SG M CRV Y


22101 PRT L EX C PS T V RT INTRNS C B1Y LE S 1 V RT SG M TH RC Y


22102 PRT L EX C PS T V RT INTRNS C B1Y LE S 1 V RT SG M LMBR Y


22110 PRT L EX C V RT BDY B1Y LE S W O SPI CORD 1 SG M CRV Y


22112 PRT L EX C V RT BDY B1Y LE S W O SPI CORD 1 SG M THRC Y


22114 PRT L EX C V RT BDY B1Y LE S W O SPI CORD 1 SG M LMBR Y






Out-Patien t Hospital/Ambulatory � Surger y Cente r (ASC ) Procedures�

22206 OSTEOTOMY SPINE POSTERIOR 3 COLUM N THORACI C Y


22207 OSTEOTOMY SPINE POSTERIOR 3 COLUM N LUMBAR

Y


22210 OSTEOTOMY SPINE PS T PSTLA T APPR 1 V RT SG M CRV Y


22212 OSTEOTOMY SPINE PS T PSTLA T APPR 1 V RT SG M TH RC

Y

Out-Patien t Hospital/Ambulatory � Surger y Cente r (ASC ) Procedures �

22214 OSTEOTOMY SPINE PS T PSTLA T APPR 1 V RT SG M LMBR Y


22220 OSTEOTOMY SPINE W DSK C AN T APPR 1 V RT SG M CRV Y


22222 OSTEOTOMY SPINE W DSK C AN T APPR 1 V RT SG M TH RC Y


22224 OSTEOTOMY SPINE W DSK C AN T APPR 1 V RT SG M LMBR Y


22505 MANIPULATIO N SPINE REQUIRIN G ANESTHESI A Y


22526 PERQ INTRDSC L ELECTROTH RM ANNULOPLASTY 1 LEVE L Y

Out-Patien t Hospital/Ambulatory � Surger y Cente r (ASC ) Procedures

22527 PERQ INTRDSC L ELECTROTH RM ANNULOPLASTY ADD L LV L Y


22532 ARTHRODESI S LATERA L EXTRACAVITARY THORACI C Y


22533 ARTHRODESI S LATERA L EXTRACAVITARY LUMBAR Y


22548 ARTHRD AN T TRANSO RL XTRORA L C1-C2 W W O EX C ODNTD Y


22551 ARTHRD AN T INTERBODY DECOMPRES S CERVICA L BELW C2 Y


22554 ARTHRD AN T MI N DISCEC T INTERBODY CE RV BELOW C2 Y


22556 ARTHRD AN T MI N DISCECTOMY INTERBODY THORACI C Y


22558 ARTHRODESI S ANTERIOR INTERBODY LUMBAR Y


22586 ARTHRODESI S PRESACRA L INTRBDY W INSTRUMEN T L5-S1 Y


22590 ARTHRODESI S POSTERIOR CRANIOCERVICA L Y


22595 ARTHRODESI S POSTERIOR ATLAS-AXI S C1-C2 Y


22600 ARTHRODESI S PS T PSTLA T CERVICA L BELW C2 SG M Y


22610 ARTHRODESI S POSTERIOR POSTEROLATERA L THORACI C

Y


22612 ARTHRODESI S POSTERIOR POSTEROLATERA L LUMBAR Y


22630 ARTHRODESI S POSTERIOR INTERBODY LUMBAR Y


22633 ARTHDSI S POS T POSTEROLAT RL POSTINTERBODY LUMBAR

Y


22800 ARTHRODESI S POSTERIOR SPINA L DF RM U P 6 V RT SE G

Y


22802 ARTHRODESI S POSTERIOR SPINA L DF RM 7-12 V RT SE G Y


22804 ARTHRODESI S POSTERIOR SPINA L DF RM 13 OR G RT V RT SE G

Y


22808 ARTHRODESI S ANTERIOR SPINA L DF RM 2-3 V RT SE G

Y


22810 ARTHRODESI S ANTERIOR SPINA L DF RM 4-7 V RT SE G Y


22812 ARTHRODESI S ANTERIOR SPINA L DF RM 8 OR G RT V RT SE G Y







22818 KYPHECTOMY SINGLE OR TWO SEGMENTS Y


22819 KYPHECTOMY 3 OR MORE SEGMENTS Y


22830 EXPLORATION SPINAL FUSION Y


22849 REINSERTION SPINAL FIXATION DEVICE Y


22850 REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION Y


22852 REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION Y


22853 Insertio n o f interbod y biomechanica l device(s ) (eg , syntheti c cage , mesh ) wit h integra l anterio r instrumentatio n fo r device anchorin g

Y Y


22854 Insertio n o f intervertebra l biomechanica l device( s) (eg , syntheti c cage , mesh ) wit h integra l anterio r instrumentatio n fo r device

Y Y


22855 REMOVAL ANTERIOR INSTRUMENTATION Y


22856 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV Y

Out-Patient Hospital/Ambulatory Surgery Cente r (ASC ) Procedures

22857 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC LMBR Y

Out-Patient Hospital/Ambulatory Surger y Cente r (ASC ) Procedures

22859 Insertio n o f intervertebra l biomechanica l device( s) (eg , synthetic cage , mesh , methylmethacrylate ) to intervertebra l disc space or

Y Y


22861 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV Y


22862 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR Y


22864 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL Y


22865 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR Y


22867 INSJ STABLJ DEV W DCMPRN LUMBAR SINGLE LEVEL Y


22868 INSJ STABLJ DEV W DCMPRN LUMBAR SECOND LEVEL Y


22869 INSJ STABLJ DEV W O DCMPRN LUMBAR SINGLE LEVEL Y


22870 INSJ STABLJ DEV W O DCMPRN LUMBAR SECOND LEVEL Y


23412 OPEN REPAIR OF ROTATOR CUFF CHRONIC Y


23470 ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


25447 ARTHRP INTERPOS INTERCARPAL METACARPAL JOINTS Y


26499 CORRECTION CLAW FINGER OTHER METHODS Y


27120 ACETABULOPLASTY Y


27122 ACETABULOPLASTY RESECTION FEMORAL HEAD Y







27125 HEMIARTHROPLASTY HIP PARTIAL Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27130 ARTHRP ACETBLR PROX FEM PROSTC AGRFT ALGRFT Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)

Out-Patien t Hospital/Ambulatory Surger y Cente r (ASC ) Procedures

27132 CONV PREV HIP TOT HIP ARTHRP W WO AGRFT ALGRFT Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27134 REVJ TOT HIP ARTHRP BTH W WO AGRFT ALGRFT Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27137 REVJ TOT HIP ARTHRP ACTBLR W WO AGRFT ALGRFT Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27138 REVJ TOT HIP ARTHRP FEM ONLY W WO ALGRFT Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27438 ARTHROPLASTY PATELLA W PROSTHESIS Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27440 ARTHROPLASTY KNEE TIBIAL PLATEAU Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27441 ARTHRP KNEE TIBIAL PLATEAU DBRDMT AND PRTL SYNVCT Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27442 ARTHROPLASTY FEM CONDYLES TIBIAL PLATEAU KNEE Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27443 ARTHRP FEM CONDYLES TIBL PLATU KNE DBRDMT AND PRTL Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27445 ARTHROPLASTY KNEE HINGE PROSTHESIS Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27446 ARTHRP KNEE CONDYLE AND PLATEAU MEDIAL LAT CMPRT Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27447 ARTH RP KNE CONDYLE AND PLAT U MEDIA L AND LA T COMPARTMENT S

Y If performed in an Out-Patient setting, NOTIFICATION ONLY (PAR Providers ONLY)


27486 REVJ TOTAL KNEE ARTHRP W WO ALGRFT 1 COMPONENT Y


27487 REVJ TOT KNEE ARTHRP FEM AND ENTIRE TIBIAL COMPONE Y


28005 INCISION BONE CORTEX FOOT Y

Out-Patient Hospital/Ambulatory Surger y Cente r (ASC ) Procedures Out-Patient Hospital/Ambulatory Surger y Cente r (ASC ) Procedures

28008 FASCIOTOMY FOOT AND TOE Y

28010 TENOTOMY PERCUTANEOUS TOE SINGLE TENDON Y


28011 TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON Y


28035 RELEASE TARSAL TUNNEL Y


28060 FASCIECTOMY PLANTAR FASCIA PARTIAL SPX Y


28062 FASCIOTOMY PLANTAR FASCIA RADICAL SPX Y


28080 EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH Y


28090 EXC LESION TENDON SHEATH CAPSULE W SYNVCT FOOT Y


28092 EXC LESION TENDON SHEATH CAPSULE W SYNVCT TOE EA Y


28100 EXCISION CURETTAGE CYST TUMOR TALUS CALCANEUS Y


28102 EXC CURTG CST B9 TUM TALUS CLCNS W ILIAC AGRFT Y


28103 EXC CURETTAGE CYST TUMOR TALUS CALCANEUS ALGRFT Y


28104 EXC CURTG BONE CYST B9 TUMORTARSAL METATARSAL Y


28106 EXC CURTG CST B9 TUM TARSAL METAR W ILIAC AGRFT Y


28107 EXC CURTG CST B9 TUM TARSAL METAR W ALGRFT Y







28108 EX C CURT G CS T B9 TU M PHALANGE S FOO T Y


28110 OSTECTOMY PRT L 5TH METAR HEAD SP X Y


28111 OSTECTOMY COMPLETE 1S T METATARSA L HEAD Y


28112 OSTECTOMY COMPLETE OTHER METATARSA L HEAD 2 3 4 Y


28113 OSTECTOMY COMPLETE 5TH METATARSA L HEAD Y


28114 OST C COMP L AL L METAR HEAD S W PRT L PRO X PHALANG C Y


28116 OSTECTOMY TARSA L COALITIO N Y


28118 OSTECTOMY CALCANEU S Y


28119 OSTECTOMY CALCANEU S SPUR W W O PLNTAR FASCIA L RLS Y


28120 PARTIA L EXCISIO N BONE TALUS CALCANEUS Y


28122 PRT L EX C B1 TARSA L METAR B1 XC P TALUS CALCANEUS Y


28124 PARTICA L EXCISIO N BONE PHALAN X TOE Y


28126 RESECTIO N PARTIA L COMPLETE PHALANGEA L BASE EACH Y


28130 TALECTOMY ASTRAGALECTOMY Y


28140 METATARSECTOMY Y


28150 PHALANGECTOMY TOE EACH TOE Y


28153 RESECTIO N CONDYLE DISTA L END PHALAN X EACH TOE Y


28160 HEMIPHALANGECTOMY INTERPHALANGEA L JOIN T EX C TOE Y


28171 RAD RESC J TUMOR TARSA L EXCEP T TALU S CALCANEU S Y


28173 RADICA L RESECTIO N TUMOR METATARSA L Y


28175 RADICA L RESECTIO N TUMOR PHALAN X OR TOE Y


28200 RPR TD N FLXR FOO T 1 2 W O FREE GRAF G EACH TENDO N Y


28202 RPR TENDO N FLXR FOO T SE C W FREE GRAF T E A TENDO N Y


28208 REPAIR TENDO N EXTENSOR FOO T 1 2 EACH TENDO N Y


28210 RPR TENDO N XTNSR FOO T SE C W FREE GRAF T E A TENDO N Y


28220 TENOLYSI S FLEXOR FOO T SINGLE TENDO N Y


28222 TENOLYSI S FLEXOR FOO T MULTIPLE TENDON S Y


28225 TENOLYSI S EXTENSOR FOO T SINGLE TENDO N Y


28226 TENOLYSI S EXTENSOR FOO T MULTIPLE TENDO N Y


28230 T X OP N TENDO N FLEXOR FOO T SINGLE MUL T TENDO N SP X Y


28232 T X OPE N TENDO N FLEXOR TOE 1 TENDO N SP X Y


28234 TENOTOMY OPE N EXTENSOR FOO T TOE EACH TENDO N Y






Out-Patien t Hospital/Ambulatory Surger y Cente r (ASC ) Procedures �

28238 RCNST J PS T TIB L TD N W EX C ACCESSORY TARS L NAVCLR Y �


28240 TENOTOMY LENGTHENIN G RL S ABDUCTOR HALLUCI S MUS C Y


28250 DIVISIO N PLANTAR FASCI A AND MUSCLE SP X Y


28260 CAPSULOTOMY MIDFOO T MEDIA L RELEASE ONLY SP X Y


28261 CAPSULOTOMY MIDFOO T W TENDO N LENGTHENIN G Y


28262 CAPSU L MIDFOO T W PS T TALOTIB L CAPSU L AND TD N LNGTH Y


28264 CAPSULOTOMY MIDTARSA L Y �


28270 CAPSU L MTTARPHLNG L J T W W O TENORRHAPHY E A J T SP X Y


28272 CAPSULOTOMY IPHA L JOIN T EACH JOIN T SP X Y


28280 SYNDACTYLIZATIO N TOE S Y


28285 CORRECTIO N HAMMERTOE Y


28286 CORRECTIO N COCK-U P 5TH TOE W PLASTI C CLOSURE Y


28288 OST C PRT L EXOST C CONDYL C METAR HEAD Y


28289 HALLU X RIGIDU S W CHEILECTOMY 1S T M P J T W O IMPL T Y


28291 HALLU X RIGIDU S W CHEILECTOMY 1S T M P J T W IMPL T Y


28292 CO RRJ HALLU X VALGU S W SESMD C W RESC J PRO X PHA L Y


28295 CO RRJ HALLU X VALGU S W SESMD C W PRO X METAR OSTEO T Y


28296 CO RRJ HALLU X VALGU S W SESMD C W DIS T METAR OSTEO T Y


28297 CO RRJ HALLU X VALGU S W SESMD C W 1METAR MEDIA L CN F Y


28298 CO RRJ HALLU X VALGU S W SESMD C W PRO X PHLN X OSTEO T Y


28299 CO RRJ HALLU X VALGU S W SESMD C W 2 OSTEO T Y


28300 OSTEOTOMY CALCANEU S W W O INTERNA L FIXATIO N Y


28302 OSTEOTOMY TALU S Y


28304 OSTEOTOMY TARSA L BONE S OTH TH N CALCANEU S TALU S Y


28305 OSTEO T TARSA L OTH TH N CALCANEU S TALU S W AGRF T Y


28306 OSTEO T W W O LNGTH SH RT CO RRJ 1S T METAR Y


28307 OSTEO T W W O LNGTH SH RT CO RRJ METAR XC P 1S T TOE Y


28308 OSTEO T W W O LNGTH SH RT CO RRJ METAR XC P 1S T E A Y


28309 OSTEO T W W O LNGTH SH RT ANGULAR CO RRJ METAR ML T Y


28310 OSTEO T SH RT CO RRJ PRO X PHALAN X 1S T TOE Y


28312 OSTEO T SH RT CO RRJ OTH PHALANGE S ANY TOE Y


28313 RCNST J ANGULAR DF RM TOE SOF T TIS S P X ONLY Y






Out-Patient Hospital/Ambulatory�Surger y Cente r (ASC ) Procedures �

28315 SESAMOIDECTOMY FIRS T TOE SP X Y


28320 REPAIR NONUNIO N MALUNIO N TARSA L BONE S Y


28322 RPR NO N MALUNIO N METARSA L W W O BONE GRAF T Y


28340 RCNST J TOE MACRODACTYLY SOF T TISSUE RESECTIO N Y


28341 RCNST J TOE MACRODACTYLY REQUIRIN G BONE RESECTIO N Y


28344 RECONSTRUCTIO N TOE POLYDACTYLY Y


28345 RCNST J TOE SYNDACTYLY W W O SKI N GRAF T EACH WEB Y


28360 RECONSTRUCTIO N CLEF T FOO T Y


28705 ARTHRODESI S PANTALAR Y


28715 ARTHRODESI S TRIPLE Y


28725 ARTHRODESI S SUBTALAR Y


28730 ARTHRD MIDTARS L TARSOMETATARSA L MUL T TRANSV RS Y


28735 ARTHRD MIDTARS L TA RS ML T TRANSV RS W OSTEO T Y


28737 ARTHRD W TD N LNGTH AND ADVMN T TARS L NVCLR-CUNEIFOR Y


28740 ARTHRODESI S MIDTARSOMETATARSA L SINGLE JOIN T Y


28750 ARTHRODESI S GREA T TOE METATARSOPHALANGEA L JOIN T Y


28755 ARTHRODESI S GREA T TOE INTERPHALANGEA L JOIN T Y


28760 ARTHRD W XTNSR HALLUCI S LONGU S TR 1S T METAR NC K Y


28890 ESW T HI N RG PHY S QH P W U S GD N INV G PLNTAR FASCI A Y


29806 ARTHROSCOPY SHOULDER SURGICA L CAPSULORRHAPHY Y �


29807 ARTHROSCOPY SHOULDER SURGICA L REPAIR SLA P LESIO N Y


29819 ARTHROSCOPY SHOULDER SURGICA L REMOVA L LOOSE FB Y


29820 ARTHROSCOPY SHOULDER SU RG SYNOVECTOMY PARTIA L Y


29821 ARTHROSCOPY SHOULDER SU RG SYNOVECTOMY COMPLETE Y


29822 ARTHROSCOPY SHOULDER SU RG DEBRIDEMEN T LIMITED Y


29823 ARTHROSCOPY SHOULDER SU RG DEBRIDEMEN T EXTENSIVE Y


29824 ARTHROSCOPY SHOULDER DISTA L CLAVICULECTOMY Y


29825 ARTHROSCOPY SHOULDER AHESIOLYSI S W W O MANIP J Y


29826 ARTHROSCOPY SHOULDER W CORACOAC RM LIGMN T RELEASE Y


29827 ARTHROSCOPY SHOULDER ROTATOR CUF F REPAIR Y


29828 ARTHROSCOPY SHOULDER BICEP S TENODESI S Y


29873 ARTHROSCOPY KNEE LATERA L RELEASE Y







29874 ARTHROSCOPY KNEE REMOVA L LOOSE FOREIG N BODY Y


29875 ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SP X Y


29876 ARTHROSCOPY KNEE SYNOVECTOMY 2 OR G RT COMPARTMENT S Y


29877 ARTH RS KNEE DEBRIDEMEN T SHAVIN G ARTCLR CRTL G Y


29879 ARTH RS KNEE ABRASIO N ARTH RP ML T DRL G MICROF X Y


29880 ARTH RS KNEE W MENISCECTOMY MED AND LA T W SHAVIN G Y


29881 ARTH RS KNE SU RG W MENISCECTOMY MED LA T W SHV G Y


29882 ARTHROSCOPY KNEE W MENISCU S RPR MEDIA L LATERA L Y


29883 ARTHROSCOPY KNEE W MENISCU S RPR MEDIA L AND LATERA L Y


29884 ARTHROSCOPY KNEE W LYSI S ADHESION S W W O MAN J SP X Y


29885 ARTH RS KNEE DRIL L OSTEOCHONDRITI S DISSECAN S GRF G Y


29886 ARTH RS KNEE DRILLIN G OSTEOCHOND DISSECAN S LESIO N Y


29887 ARTH RS KNEE DRL G OSTEOCHOND DISSECAN S IN T FIX J Y


29888 ARTH RS AIDED AN T CRUCIATE LIG M RPR AGMNT J RCNST J Y


29889 ARTH RS AIDED PS T CRUCIATE LIG M RPR AGMNT J RCNST J Y


29891 ARTH RS ANKLE EX C OSTCHND RL DFC T W DRL G DFC T Y


29892 ARTH RS AID RPR LE S TALAR DOME F X TIB L PLAFOND F X Y


29893 ENDOSCOPI C PLANTAR FASCIOTOMY Y


29894 ARTHROSCOPY ANKLE W REMOVA L LOOSE FOREIG N BODY Y


29895 ARTHROSCOPY ANKLE SURGICA L SYNOVECTOMY PARTIA L Y


29897 ARTHROSCOPY ANKLE SURGICA L DEBRIDEMEN T LIMITED Y


29898 ARTHROSCOPY ANKLE SURGICA L DEBRIDEMEN T EXTENSIVE Y


29899 ARTHROSCOPY ANKLE SURGICA L W ANKLE ARTHRODESI S Y


29914 ARTHROSCOPY HI P W FEMOROPLASTY Y


29915 ARTHROSCOPY HI P W ACETABULOPLASTY Y


29916 ARTHROSCOPY HI P W LABRA L REPAIR Y


30465 REPAIR NASA L VESTIBULAR STENOSI S Y


30520 SEPTOPLASTY SUBMUCOU S RESEC J W W O CARTILAGE G RF Y


30540 REPAIR CHOANA L ATRESI A INTRANASA L Y


30545 REPAIR CHOANA L ATRESI A TRANSPALATINE Y


31253 NASA L SINU S NDS C TO T W FRN T SIN S EXP L TIS S RMV L Y �


31257 NASA L SINU S NDS C TOTA L WITH SPHENOIDOTOMY Y







31259 NASA L SINU S NDS C TO T W SPHEND T W SPHE N TIS S RMV L Y � �


� 31295 NASA L SINU S NDS C SU RG W DILA T MAXILLARY SINU S Y �


31296 NASA L SINU S NDS C SU RG W DILATIO N FRONTA L SINU S Y


31297 NASA L SINU S NDS C SU RG W DILATIO N SPHENOID SINU S Y


31298 NASA L SINU S NDS C W FRONTA L AND SPHE N SIN S DILATIO N Y


31660 BRONCHOSCOPI C THERMOPLASTY ONE LOBE Y


31661 BRONCHOSCOPI C THERMOPLASTY 2 OR G RT LOBE S Y


32491 RMV L LUN G OTH TH N PNUME C RESXN-PLCT J EMPHY LUN G Y


32850 Dono r pneumonectomy( s) (includin g col d preservation) , from cadave r donor

Y


33251 ABLATIO N ARRHYTHMOGENI C FOCI PATHWAY W BYPAS S Y


33254 ABLATIO N AND RECONSTRUCTIO N ATRI A LIMITED Y


33261 OPRATIVE ABLT J VENTR ARRHYTHMOGENI C FO C W BYPAS S Y


33265 NDS C ABLATIO N AND RCNST J ATRI A LIMITED W O BYPA S Y


33266 NDS C ABLATIO N AND RCNST J ATRI A EXTE N W O BYPAS S Y


33274 TCA T INS J RP L PE RM LEADLES S PACEMAKER RV W IM G Y


33289 TCA T IMP L WRL S P-A RT P RS SNR L- T HEMODY N MNTR Y


33979 INS J VENTR ASSIS T DE V IMPLTABLE ICO RP 1 VNT RC Y �


36460 TRANSFUSIO N INTRAUTERINE FETA L Y


36465 NJ X NONCMPND SCLEROSAN T SINGLE INCMPTN T VEI N Y �


36466 NJ X NONCMPND SCLEROSAN T MULTIPLE INCMPTN T VEIN S Y


36468 INJECTION S SCLEROSAN T FOR SPIDER VEIN S LI M TRN K Y


36470 INJECTIO N SCLEROSAN T SINGLE INCMPTN T VEI N Y


36471 INJECTIO N SCLEROSAN T MULTIPLE INCMPTN T VEIN S Y


36475 ENDOVE N ABLT J INCMPTN T VEI N XTR RF 1S T VEI N Y


� 36476 ENDOVE N ABLT J INCMPTN T VEI N XTR RF 2ND PLU S VEIN S Y �


� 36478 ENDOVE N ABLT J INCMPTN T VEI N XTR LASER 1S T VEI N Y �


� 36479 ENDOVE N ABLT J INCMPTN T VEI N XTR LASER 2ND PLU S VEIN S Y �


� 36482 ENDOVE N ABLTI THER CHE M ADHESIVE 1S T VEI N Y �


� 36483 ENDOVE N ABLTI THER CHE M ADHESIVE SBSQ VEI N Y �


� 36514 THERAPEUTI C APHERESI S PLASM A PHERESI S Y �


� 37191 IN S INTRVA S V C FILTR W W O VA S AC S VS L SELX N RS AND I Y �


� 37243 VASCULAR EMBOLIZE OCCLUDE ORGA N TUMOR INFARC T Y �







37700 LI G AND DI V LON G SAPH VEI N SAPHFE M JUNC T INTERRUPJ Y


37718 LIG J DIV J AND STRIPPIN G SHO RT SAPHENOU S VEI N Y


37722 LIG J DIV J AND STRI P LON G SAPH SAPHFE M JUNC T KNE BELW Y


37735 LIG J AND DIV J RADICA L STRI P LON G SHO RT SAPHENOU S Y �


37760 LI G PRFRATR VEI N SUBFSCA L RAD INC L SK N G RF 1 LE G Y ��


37761 LI G PRFRATR VEI N SUBFSCA L OPE N INC L U S GID 1 LE G Y �


37765 STAB PHLEB T VARICOSE VEIN S 1 XTR 10-20 STAB INC S Y


37766 STAB PHLEB T VARICOSE VEIN S 1 XTR OVER 20 INC S Y


37780 LIG J AND DI V SHO RT SAPH VEI N SAPHENOPO P JUNC T SP X Y


37785 LIG J DIV J AND EXC J VARICOSE VEI N CLUSTER 1 LE G Y �


38204 MGM T RC P HEMATO P PROGENITOR CEL L DONOR AND ACQUIS J Y


38207 TRNSP L PREP J HEMATO P PROGE N CELL S CRYOPRS RV STOR Y


38208 TRNSP L PRE P HEMATO P PROGE N THAW PRE V H RV PER DNR Y


38209 TRNS P PRE P HMATO P PRO G THAW PRE V H RV WSH PER DNR Y


38210 TRNSP L PREP J HEMATO P PROGE N DEPL J I N H RV T-CEL L Y


38211 TRNSP L PREP J HEMATO P PROGE N TU M CEL L DEPL J Y


38212 TRNSP L PREP J HEMATO P PROGE N RED BLD CEL L RMV L Y


38213 TRNSP L PREP J HEMATO P PROGE N PLTL T DEPL J Y


38214 TRNSP L PREP J HEMATO P PROGE N PLS M VO L DEPL J Y


38215 TRNSP L PREP J HEMATO P PROGE N CONCENTRATIO N PLS M Y


38232 BONE MARROW HARVES T TRANSPLANTATIO N AUTOLOGOU S Y


43644 LAP S GSTR RSTC V P X W BY P ROUX-EN-Y LIMB UNDER 150 C M Y


43645 LAP S GSTR RSTC V P X W BY P AND S M IN T RCNST J Y


43647 LAP S IMPLT J RPLCM T GASTRI C NSTI M ELTRD ANTRU M Y


43648 LAP S REVISIO N RMV L GASTRI C NSTI M ELTRD ANTRU M Y


43653 LAP S SU RG GASTROSTOMY W O CONST J GSTR TUBE SP X Y


43770 LAP S GASTRI C RESTRICTIVE PROCEDURE PLACE DEVICE Y


43771 LAP S GASTRI C RESTRICTIVE P X REVISIO N DEVICE Y


43772 LAP S GASTRI C RESTRICTIVE P X REMOVE DEVICE Y


43773 LAP S GASTRI C RESTRICTIVE P X REMOVE AND RPLCM T DEVICE Y


43774 LAP S GASTRI C RESTRICTIVE P X REMOVE DEVICE AND PO RT Y


43775 LAP S GST RC RSTRICTI V P X LONGITUDINA L GASTRECTOMY Y







43842 GASTRI C RSTC V W O BY P VERTICAL-BANDED GASTROPLY Y


43843 GSTR RSTC V W O BY P OTH TH N VER-BANDED GST P Y


43845 GASTRI C RSTC V W PRT L GASTRECTOMY 50-100 C M Y


43846 GASTRI C RSTC V W BY P W SHO RT LIMB 150 C M OR LES S Y


43847 GASTRI C RSTC V W BY P W S M IN T RCNST J LIMI T ABSRP J Y


43848 REVISIO N OPE N GASTRI C RESTRICTIVE P X NO T DEVICE Y


43881 IMPLT J RPLCM T GASTRI C NSTI M ELTRDE ANTRU M OPE N Y


43882 REVISIO N RMV L GASTRI C NSTI M ELTRDE ANTRU M OPE N Y �


43886 GSTR RSTC V P X OP N REV J SUBQ PO RT COMPONEN T ONLY Y


43887 GSTR RSTC V P X OP N RMV L SUBQ PO RT COMPONEN T ONLY Y


43888 GSTR RSTC V OP N RMV L AND RPLCM T SUBQ PO RT Y �


47380 ABLT J OP N 1 OR G RT LVR TU M RF Y


47381 ABLT J OP N 1 OR G RT LVR TU M CRYOSU RG Y

Out-Patien t Hospital/Ambulatory Surger y Cente r (ASC ) Procedures�

47382 ABLT J 1 OR G RT LVR TU M PRQ RF Y �


47605 CHOLECYSTECTOMY W CHOLANGIOGRAPHY Y �


47610 CHOLECYSTECTOMY W EXPLORATIO N COMMO N DUC T Y


47612 CHOLECYSTECTOMY EXP L DUC T CHOLEDOCHOENTEROSTOMY Y


47620 CHOLECST C EXP L DU X SPHNCTROTOMY SPHNCTRO P Y


49255 OMNT C EPIPLOECTOMY RESC J OMENTU M SP X Y �


49904 OMENTA L FLA P EXTRA-ABDOMINA L Y


49906 FREE OMENTA L FLA P W MICROVASCULAR ANAS T Y


52441 CYST O INSERTIO N TRANSPROSTATI C IMPLAN T SINGLE Y


52649 LASER ENUCLEATIO N PROSTATE W MORCELLATIO N Y


53850 TRU RL DST RJ PRSTATE TIS S MICROWAVE THERMOTH Y


53852 TRU RL DST RJ PRSTATE TIS S RF THERMOTH Y


53854 TRU RL DST RJ PRST8 TIS S RF W V THERMOTHERAPY Y


54401 INS J PENILE PROSTHESO S INFLATABLE SELF-CONTAINED Y


54405 INS J MULTI-COMPONEN T INFLATABLE PENILE PROSTH Y


57288 SLIN G OPERATIO N STRES S INCONTINENCE Y


57289 PEREY RA P X W ANTERIOR COLPORRHAPHY Y


58150 TOTA L ABDOMINA L HYSTEREC T W W O RMV L TUBE OVARY Y


58152 TO T ABD HYS T W W O RMV L TUBE OVARY W COLPURETHRXY Y







58180 SUPRACERVICAL ABDL HYSTER W WO RMVL TUBE OVARY Y


58200 TOT ABD HYST W PARAORTIC AND PELVIC LYMPH NODE SAM Y


58210 RAD ABDL HYSTERECTOMY W BI PELVIC LMPHADENECTOMY Y


58240 PEL EXNTJ GYNECOLOGIC MAL Y


58260 VAGINAL HYSTERECTOMY UTERUS 250 GM OR LESS Y


58262 VAG HYST 250 GM OR LESS W RMVL TUBE AND OVARY Y


58263 VAG HYST 250 GM OR LESS W RMVL TUBE OVARY W RPR NTRCL Y


58267 VAG HYST 250 GM OR LESS W COLPO-URTCSTOPEXY Y


58270 VAGINAL HYSTERECTOMY 250 GM OR LESS W RPR ENTEROCELE Y


58275 VAGINAL HYSTERECTOMY W TOT PRTL VAGINECTOMY Y


58280 VAG HYSTER W TOT PRTL VAGINECT W RPR ENTEROCELE Y


58285 VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION Y


58290 VAGINAL HYSTERECTOMY UTERUS OVER 250 GM Y


58291 VAG HYST OVER 250 GM RMVL TUBE AND OVARY Y


58292 VAG HYST OVER 250 GM RMVL TUBE AND OVARY W RPR ENTRCLE Y


58293 VAG HYST OVER 250 GM COLPOURTCSTOPEXY W WO NDSC CTR Y


58294 VAGINAL HYSTERECTOMY OVER 250 GM RPR ENTEROCELE Y


58321 ARTIFICIAL INSEMINATION INTRA-CERVICAL Y


58322 ARTIFICIAL INSEMINATION INTRA-UTERINE Y


58323 SPERM WASHING ARTIFICIAL INSEMINATION Y


58345 TRANSCERV FALLOPIAN TUBE CATH W WO HYSTOSALPING Y


58350 CHROMOTUBATION OVIDUCT W MATERIALS Y


58356 ENDOMETRIAL CRYOABLATION W US AND ENDOMETRIAL CR Y


58540 HYSTEROPLASTY RPR UTERINE ANOMALY Y


58541 LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM OR LESS Y


58542 LAPS SUPRACRV HYSTERECT 250 GM OR LESS RMVL TUBE OVAR Y


58543 LAPS SUPRACERVICAL HYSTERECTOMY OVER 250 Y


58544 LAPS SUPRACRV HYSTEREC OVER 250 G RMVL TUBE OVARY Y


58545 LAPS MYOMECTOMY EXC 1-4 MYOMAS 250 GM OR LESS Y


58546 LAPS MYOMECTOMY EXC 5 OR GRT MYOMAS OVER 250 GRAMS Y


58548 LAPS W RAD HYST W BILAT LMPHADEC RMVL TUBE OVARY Y


58550 LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM OR LESS Y







58552 LAPS W VAG HYSTERECT 250 GM AND RMVL TUBE AND OVARIES Y


58553 LAPS W VAGINAL HYSTERECTOMY OVER 250 GRAMS Y


58554 LAPS VAGINAL HYSTERECT OVER 250 GM RMVL TUBE AND OVAR Y


58570 LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM OR LESS Y


58571 LAPS TOTAL HYSTERECT 250 GM OR LESS W RMVL TUBE OVARY Y


58572 LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS OVER 250 GM Y


58573 LAPAROSCOPY TOT HYSTERECTOMY OVER 250 G W TUBE OVAR Y


58660 LAPAROSCOPY W LYSIS OF ADHESIONS Y


58661 LAPAROSCOPY W RMVL ADNEXAL STRUCTURES Y


58662 LAPS FULG EXC OVARY VISCERA PERITONEAL SURFACE Y


58672 LAPAROSCOPY FIMBRIOPLASTY Y


58673 LAPAROSCOPY SALPINGOSTOMY Y


58700 SALPINGECTOMY COMPLETE PARTIAL UNI BI SPX Y


58720 SALPINGO-OOPHORECTOMY COMPL PRTL UNI BI SPX Y


58740 LYSIS OF ADHESIONS SALPINX OVARY Y


58750 TUBOTUBAL ANASTATOMOSIS Y


58752 TUBOUTERINE IMPLANTATION Y


58760 FIMBRIOPLASTY Y


58770 SALPINGOSTOMY Y


58940 OOPHORECTOMY PARTIAL TOTAL UNI BI Y


58943 OOPHORECTOMY PRTL TOT UNI BI OVARIAN MALIGNANCY Y


58950 RESCJ OVARIAN TUBAL PERITONEAL MALIGNANCY W BSO Y


58951 RESCJ PRIM PRTL MAL W BSO AND OMNTC TAH AND LMPHAD Y


58952 RESCJ PRIM PRTL MAL W BSO AND OMNTC RAD DEBULKING Y


58953 BSO W OMENTECTOMY TAH AND RAD DEBULKING DISSECTION Y


58954 BSO W OMENTECTOMY TAH DEBULKING W LMPHADECTOMY Y


58956 BSO W TOT OMENTECTOMY AND HYSTERECTOMY MALIGNANC Y


58957 RESECJ RECUR OVARIAN TUBAL PERITONEAL MALIGNANCY Y


58958 RESECTION RECRT MAL W OMENTECTOMY PEL LMPHADEC Y


58970 FOLLICLE PUNCTURE OOCYTE RETRIEVAL ANY METHOD Y


58974 EMBRYO TRANSFER INTRAUTERINE Y


58976 GAMETE ZYGOTE EMBRYO FALLOPIAN TRANSFER ANY METH Y







59070 TRANSABDOMINA L AMNIOINFUSIO N W ULTRSND GUIDANCE Y


59072 FETA L UMBILICA L CORD OCCLUSIO N W ULTRSND GUIDNCE Y


59074 FETA L FLUID DRAINAGE W ULTRASOUND GUIDANCE Y


59076 FETA L SHUN T PLACEMEN T W ULTRASOUND GUIDANCE Y


61863 STRTCT C IMPLT J NSTI M ELTRD W O RECORD 1S T ARRAY Y


61867 STRTCT C IMPLT J NSTI M ELTRD W RECORD 1S T ARRAY Y �


61885 INS J RPLCM T CRANIA L NEUROSTI M PULSE GENERATOR Y �


61886 INS J RPLCM T CRANIA L NEUROSTI M GENER 2 OR G RT ELTRD S Y


62324 NJ X D X THER SBS T INTRLMNR C RV TH RC W O IM G GD N Y


62325 NJ X D X THER SBS T INTRLMNR C RV TH RC W IM G GD N Y


62326 NJ X D X THER SBS T INTRLMNR LMBR SA C W O IM G GD N Y


62327 NJ X D X THER SBS T INTRLMNR LMBR SA C W IM G GD N Y


62369 ELEC T ANLY S IMPL T ITHC L ED RL PM P W REP RG AND REFI L Y


62370 ELE C ANLY S IMPL T ITHC L ED RL PM P W REPR PHY S QH P Y


62380 NDS C DCMP RN SPINA L CORD 1 W LAMO T NTRSP C LUMBAR Y


63001 LA M W O FACETE C FORAMO T DSK C 1 2 V RT SE G CRV Y


63003 LAMINECTOMY W O FFD 1 2 VE RT SE G THORACI C Y


63005 LAMINECTOMY W O FFD 1 2 VE RT SE G LUMBAR Y


63011 LAMINECTOMY W O FFD 1 2 VE RT SE G SACRA L Y


63012 LAMINECTOMY W RMV L ABNORMA L FACET S LUMBAR Y


63015 LAMINECTOMY W O FFD OVER 2 VE RT SE G CERVICA L Y


63016 LAMINECTOMY W O FFD OVER 2 VE RT SE G THORACI C Y


63017 LAMINECTOMY W O FFD OVER 2 VE RT SE G LUMBAR Y �


63020 LAMNOTMY INC L W DCMPRS N N RV ROO T 1 INTRSP C CERV C Y �


63030 LAMNOTMY INC L W DCMPRS N N RV ROO T 1 INTRSP C LUMBR Y


63040 LAMO T PRT L FFD EX C DIS C REEXP L 1 NTRSP C CERVICA L Y �


63042 LAMO T PRT L FFD EX C DIS C REEXP L 1 NTRSP C LUMBAR Y �


63045 LA M FACETECTOMY AND FORAMOTOMY 1 SEGMEN T CERVICA L Y


63046 LA M FACETECTOMY AND FORAMOTOMY 1 SEGMEN T THORACI C Y �


63047 LA M FACETECTOMY AND FORAMOTOMY 1 SEGMEN T LUMBAR Y


63050 LAMO P CERVICA L W DCMP RN SPI CORD 2 OR G RT VE RT SE G Y


63051 LAMOPLASTY CERVICA L DCMP RN CORD 2 OR G RT SE G RCNST J Y �







63055 TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG THORACIC Y


63056 TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG LUMBAR Y


63064 COSTOVERTEBRAL DCMPRN SPINAL CORD THORACIC 1 SEG Y


63075 DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC Y


63077 DISCECTOMY ANT DCMPRN CORD THORACIC 1 NTRSPC Y


63081 VERTEBRAL CORPECTOMY ANT DCMPRN CERVICAL 1 SEG Y


63085 VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC 1 SEG Y


63087 VCRPEC THORACOLMBR DCMPRN LWR THRC LMBR 1 SEG Y


63090 VCRPEC TRANSPRTL RPR DCMPRN THRC LMBR SAC 1 SEG Y


63101 VERTEB CORPECT LAT XTRCAVITARY DCMPRN THRC 1 SEG Y


63102 VERTEB CORPECT LAT XTRCAVITARY DCMPRN LMBR 1 SEG Y


64553 PRQ IMPLTJ NEUROSTIMULATOR ELTRD CRANIAL NERVE Y


64568 INC IMPLTJ CRNL NRV NSTIM ELTRDS AND PULSE GENER Y


64569 REVISION REPLMT NEUROSTIMLATOR ELTRD CRANIAL NRV Y


64570 REMOVAL CRNL NRV NSTIM ELTRDS AND PULSE GENERATO Y


64590 INSERTION RPLCMT PERIPHERAL GASTRIC NPGR Y


64595 REVISION RMVL PERIPHERAL GASTRIC NPGR Y


64615 Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal , cervica l spina l an d accessor y nerve s, bilatera l (eg , for

Y Y


65771 RADIAL KERATOTOMY Y


65772 CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM Y


65775 CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM Y


67900 REPAIR BROW PTOSIS Y


67901 RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR OTH MATRL Y


67902 RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING Y


67903 RPR BLEPHAROPTOSIS LEVATOR RESCJ ADVMNT INTERNAL Y


67909 REDUCTION OVERCORRECTION PTOSIS Y


67950 CANTHOPLASTY Y


69714 IMPLTJ OSSEOINTEGRATED TEMPORAL BONE W MASTOID Y


69715 IMPLJ OSSEOINTEGRATED TEMPORAL BONE W O MASTOID Y


69717 RPLMCT OSSEOINTEGRATE IMPLNT W O MASTOIDECTOMY Y


69718 RPLMCT OSSEOINTEGRATE IMPLNT W MASTOIDECTOMY Y


69930 COCHLEAR DEVICE IMPLANTATION W WO MASTOIDECTOMY Y







93229 XTRNL MOBILE CV TELEMETRY W TECHNICAL SUPPORT Y


95249 CONT GLUC MONITORING PATIENT PROVIDED EQUIPTMENT Y


95250 Ambulatory continuous glucose monitoring of interstitial tissue flui d vi a a subcutaneous senso r fo r a minimum o f 72 hours ;

Y Y


95251 Ambulator y continuous glucose monitorin g o f interstitia l tissue fluid via a subcutaneous sensor for a minimum of 72 hours;

Y Y


96567 PDT DSTR PRMLG LES SKN ILLUM ACTIVJ PER DAY Y


96570 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX 30 MIN Y

Out-Patient Hospital/Ambulatory Surgery Cente r (ASC) Procedures

96571 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX A 15 MIN Y


96573 PDT DSTR PRMLG LES SKN ILLUM ACTIVJ BY PHYS QHP Y


96574 DEBRIDEMENT PRMLG HYPERKERATOTIC LES W PDT Y


96900 ACTINOTHERAPY ULTRAVIOLET LIGHT Y


96902 MCRSCP XM HAIR PLUCK CLIP FOR CNTS STRUCT ABNORM Y


96904 WHOLE BODY INTEGUMENTARY PHOTOGRAPHY Y


96910 PHOTOCHEMOTX TAR AND UVB PETROLATUM UVB Y


96912 PHOTOCHEMOTX PSORALENS AND ULTRAVIOLET PUVA Y


96913 PHOTOCHEMOTHERAPY DERMATOSES 4-8 HRS SUPERVISION Y


96920 LASER SKIN DISEASE PSORIASIS TOT AREA UNDER 250 SQ CM Y


96921 LASER SKIN DISEASE PSORIASIS 250-500 SQ CM Y


96922 LASER SKIN DISEASE PSORIASIS OVER 500 SQ CM Y


96931 RCM CELULR AND SUBCELULR SKN IMGNG IMG ACQ I AND R 1ST Y


96932 RCM CELULR AND SUBCELULR SKN IMGNG IMG ACQUISITION Y


96933 RCM CELULR AND SUBCELULR SKN IMGNG I AND R 1ST LES Y


96934 RCM CELULR AND SUBCELULR SKN IMGNG IMG ACQ I AND R ADD Y


96935 RCM CELULR AND SUBCELULR SKN IMGNG IMG ACQ EA ADDL Y


96936 RCM CELULR AND SUBCELULR SKN IMGNG I AND R EA ADDL Y


C2616 BRACHYTHERAPY NONSTRANDED YTTRIUM-90 PER SOURCE Y


C9734 FOCUSED U S ABL TX INT OTH THAN UT LEIOMYOMATA Y


C9739 CYSTURETHRSCPY INSRT TRANSPROSTAT IMPL; 1-3 IMPL Y


C9740 CYSTURETHRSCPY INSRT TRANSPROSTAT IMPL; 4 OR GRT IMPL Y


C9747 ABLATION PROSTATE TRANSRECTAL HIFU INCL I GUID Y


C9757 Laminotomy (hemilaminectomy), with decompression of nerve root(s) , includin g partia l facetectomy , foraminotom y an d excision

Y




e sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)ches, including imaging guidance, when performed

maging guidance, when performedimage guidance (ie, fluoroscopy or computed tomography)




G2170 AVF BY TISSUE W THERMAL E Y


G2171 AVF USE MAGNETIC/ART/VEN Y


S2095 TRNSCATH OCCL EMBOLIZ TUMR DESTRUC PERQ METH USI Y

Pain Management Procedures 27096 INJECT SI JOINT ARTHRGRPHY AND ANES STEROID W IMA Y Except trigger point injections Pain Management Procedures 27279 ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS Y Except trigger point injections Pain Management Procedures 62263 PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2 OR GRT DAYS Y Except trigger point injections Pain Management Procedures 62264 PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY Y Except trigger point injections Pain Management Procedures 62320 NJX DX THER SBST INTRLMNR CRV THRC W O IMG GDN Y Except trigger point injections Pain Management Procedures 62321 NJX DX THER SBST INTRLMNR CRV THRC W IMG GDN Y Except trigger point injections Pain Management Procedures 62322 NJX DX THER SBST INTRLMNR LMBR SAC W O IMG GDN Y Except trigger point injections Pain Management Procedures 62323 NJX DX THER SBST INTRLMNR LMBR SAC W IMG GDN Y Except trigger point injections Pain Management Procedures 62350 IMPLTJ REVJ RPSG ITHCL EDRL CATH PMP W O LAM Y Except trigger point injections Pain Management Procedures 62351 IMPLTJ REVJ RPSG ITHCL EDRL CATH W LAM Y Except trigger point injections Pain Management Procedures 62360 IMPLTJ RPLCMT ITHCL EDRL DRUG NFS SUBQ RSVR Y Except trigger point injections Pain Management Procedures 62361 IMPLTJ RPLCMT FS NON-PRGRBL PUMP Y Except trigger point injections Pain Management Procedures 62362 IMPLTJ RPLCMT ITHCL EDRL DRUG NFS PRGRBL PUMP Y Except trigger point injections Pain Management Procedures 62367 ELECT ANLYS IMPLT ITHCL EDRL PMP W O REPRG REFIL Y Except trigger point injections Pain Management Procedures 62368 ELECT ANALYS IMPLT ITHCL EDRL PUMP W REPRGRMG Y Except trigger point injections Pain Management Procedures 63650 PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL Y Except trigger point injections Pain Management Procedures 63655 LAM IMPLTJ NSTIM ELTRDS PLATE PADDLE EDRL Y Except trigger point injections Pain Management Procedures 63661 RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR Y Except trigger point injections Pain Management Procedures 63662 RMVL SPINAL NSTIM ELTRD PLATE PADDLE INCL FLUOR Y Except trigger point injections Pain Management Procedures 63663 REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR Y Except trigger point injections Pain Management Procedures 63664 REVJ INCL RPLCMT NSTIM ELTRD PLT PDLE INCL FLUOR Y Except trigger point injections Pain Management Procedures 63685 INSJ RPLCMT SPI NPGR DIR INDUXIVE COUPLING Y Except trigger point injections Pain Management Procedures 63688 REVJ RMVL IMPLANTED SPINAL NEUROSTIM GENERATOR Y Except trigger point injections Pain Management Procedures 64450 INJECTION ANES OTHER PERIPHERAL NERVE BRANCH Y Except trigger point injections Pain Management Procedures 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating th Y Except trigger point injections Pain Management Procedures 64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve bran Y Except trigger point injections Pain Management Procedures 64461 PVB THORACIC SINGLE INJECTION SITE W IMG GID Y Except trigger point injections Pain Management Procedures 64462 PVB THORACIC SECOND AND ADDL INJ SITE W IMG GID Y Except trigger point injections Pain Management Procedures 64463 PVB THORACIC CONT CATHETER INFUSION W IMG GID Y Except trigger point injections Pain Management Procedures 64479 NJX ANES AND STRD W IMG TFRML EDRL CRV THRC 1 LVL Y Except trigger point injections Pain Management Procedures 64480 NJX ANES AND STRD W IMG TFRML EDRL CRV THRC EA LV Y Except trigger point injections Pain Management Procedures 64483 NJX ANES AND STRD W IMG TFRML EDRL LMBR SAC 1 LVL Y Except trigger point injections Pain Management Procedures 64484 NJX ANES AND STRD W IMG TFRML EDRL LMBR SAC EA LV Y Except trigger point injections Pain Management Procedures 64486 TAP BLOCK UNILATERAL BY INJECTION(S) Y Except trigger point injections Pain Management Procedures 64487 TAP BLOCK UNILATERAL BY CONTINUOUS INFUSION(S) Y Except trigger point injections Pain Management Procedures 64489 TAP BLOCK BILATERAL BY CONTINUOUS INFUSION(S) Y Except trigger point injections Pain Management Procedures 64490 NJX DX THER AGT PVRT FACET JT CRV THRC 1 LEVEL Y Except trigger point injections Pain Management Procedures 64491 NJX DX THER AGT PVRT FACET JT CRV THRC 2ND LEVEL Y Except trigger point injections Pain Management Procedures 64492 NJX DX THER AGT PVRT FACET JT CRV THRC 3 PLUS LEVEL Y Except trigger point injections Pain Management Procedures 64493 NJX DX THER AGT PVRT FACET JT LMBR SAC 1 LEVEL Y Except trigger point injections Pain Management Procedures 64494 NJX DX THER AGT PVRT FACET JT LMBR SAC 2ND LEVEL Y Except trigger point injections Pain Management Procedures 64495 NJX DX THER AGT PVRT FACET JT LMBR SAC 3 PLUS LEVEL Y Except trigger point injections Pain Management Procedures 64600 DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH Y Except trigger point injections Pain Management Procedures 64624 Destruction by neurolytic agent, genicular nerve branches including i Y Except trigger point injections Pain Management Procedures 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with Y Except trigger point injections Pain Management Procedures 64633 DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL THORA Y Except trigger point injections Pain Management Procedures 64634 DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL THORA Y Except trigger point injections Pain Management Procedures 64635 DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR SACRAL Y Except trigger point injections Pain Management Procedures 64636 DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR SACRAL Y Except trigger point injections Pain Management Procedures 64640 DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE Y Except trigger point injections Pain Management Procedures G0260 Injection procedure for sacroiliac joint; provision of anesthetic,

steroi d and/o r othe r therapeutic agent , wit h o r withou t arthrography

Y Except trigger point injections

Physical Therapy 97010 Application of a modality to 1 or more areas; hot or cold packs Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior

authorizatio n fo r Physica l Therapy. I n Sout h Carolina , 97112 is no t reimbursable to Physica l Therap y Providers. Prio r Authorizatio n requests wit h a Physica l Therapis t as the

servicin g provide r wil l be denie d fo r 9711 2









Physica l Therapy 97012 Applicatio n o f a modalit y to 1 o r more area s; traction , mechanical Y Y Age s 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plus the firs t si x (6 ) visit s fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior

authorizatio n fo r Physica l Therapy. I n Sout h Carolina , 97112 i s no t reimbursable to Physica l Therap y Providers. Prio r Authorizatio n requests wit h a Physica l Therapis t as the

servicin g provide r wil l be denie d fo r 97112 Physical Therapy 97014 Applicatio n o f a modalit y to 1 o r more area s; electrica l stimulation

(unattended) Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the

firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior authorizatio n fo r Physica l Therapy. I n Sout h Carolina , 97112 is no t reimbursable to

Physica l Therap y Providers. Prio r Authorizatio n requests wit h a Physica l Therapis t as the servicin g provide r wil l be denie d fo r 9711 2

Physical Therapy 97016 Application of a modality to 1 or more areas; vasopneumatic devices

Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior


servicin g provide r wil l be denie d fo r 9711 2 Physical Therapy 97018 Application of a modality to 1 or more areas; paraffin bath Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the



Physical Therapy 97022 Application of a modality to 1 or more areas; whirlpool Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior


servicin g provide r wil l be denie d fo r 9711 2 Physical Therapy 97024 Application of a modality to 1 or more areas; diathermy (eg,

microwave) Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the



Physical Therapy 97026 Application of a modality to 1 or more areas; infrared Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior


servicin g provide r wil l be denie d fo r 9711 2 Physical Therapy 97028 Application of a modality to 1 or more areas; ultraviolet Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the



Physical Therapy 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes



servicin g provide r wil l be denie d fo r 9711 2 Physical Therapy 97033 Application of a modality to 1 or more areas; iontophoresis, each 15

minutes Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the

firs t si x (6 ) visits fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior authorizatio n fo r Physica l Therapy. I n Sout h Carolina , 97112 i s no t reimbursable to


Physical Therapy 97034 Application of a modality to 1 or more areas; contrast baths, each 15 minutes



servicin g provide r wil l be denie d fo r 9711 2 Physical Therapy 97035 Application of a modality to 1 or more areas; ultrasound, each 15

minutes Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the



Physical Therapy 97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes


authorizatio n fo r Physica l Therapy. I n Sout h Carolina , 97112 i s no t reimbursable to Physica l Therap y Providers. Prio r Authorizatio n requests wit h a Physica l Therapis t as the

servicin g provide r wil l be denie d fo r 9711 2

75



Physical Therapy 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility


authorization for Physical Therapy. In South Carolina, 97112 is not reimbursable to Physical Therapy Providers. Prior Authorization requests with a Physical Therapist as the

servicing provider will be denied for 97112 Physical Therapy 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic

therapy with therapeutic exercises Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the

first six (6) visits for Outpatient settings. Ages 19 and over do NOT require prior authorization for Physical Therapy. In South Carolina, 97112 is not reimbursable to

Physical Therapy Providers. Prior Authorization requests with a Physical Therapist as the servicing provider will be denied for 97112

Physical Therapy 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)



servicing provider will be denied for 97112 Physical Therapy 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage,

including effleurage, petrissage and/or tapotement (stroking, compression, percussion)



servicing provider will be denied for 97112 Physical Therapy 97129 Therapeutic interventions that focus on cognitive function (eg,

attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes



servicing provider will be denied for 97112

Physical Therapy 97130 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure)




Physical Therapy 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes



servicing provider will be denied for 97112 Physical Therapy 97150 Therapeutic procedure(s), group (2 or more individuals) Y Y Ages 18 and younger require prior authorization after the initial evaluation/visit plus the

first six (6) visits for Outpatient settings. Ages 19 and over do NOT require prior authorization for Physical Therapy. In South Carolina, 97112 is not reimbursable to

Physical Therapy Providers. Prior Authorization requests with a Physical Therapist as the servicing provider will be denied for 97112

Physical Therapy 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes



servicing provider will be denied for 97112 Physical Therapy 97533 Sensory integrative techniques to enhance sensory processing and

promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes



servicing provider will be denied for 97112 Physical Therapy 97535 Self-care/home management training (eg, activities of daily living

(ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes



servicing provider will be denied for 97112 Physical Therapy 97537 Community/work reintegration training (eg, shopping,

transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes









Physica l Therapy 97542 Wheelchai r managemen t (eg , assessment , fitting , training) , ea ch 15 minutes



servicin g provide r wil l be denie d fo r 97112 Physica l Therapy 97760 Orthotic( s) managemen t an d trainin g (includin g assessmen t and

fittin g whe n no t otherwise reported) , uppe r extremity(ies) , lower extremity(ie s) and/o r trunk , initia l orthotic( s) encounter , ea ch 15 minutes



servicin g provide r wil l be denie d fo r 97112 Physica l Therapy 97761 Prosthetic(s ) training , uppe r and/o r lowe r extremity(ies) , initial

prosthetic( s) encounter , ea ch 15 minutes Y Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plus the


Physica l Therap y Providers. Prio r Authorizatio n requests wit h a Physica l Therapis t as the servicin g provide r wil l be denie d fo r 97112

Physica l Therapy 97763 Orthotic(s)/prosthetic( s) managemen t and/o r training , upper extremity(ies) , lowe r extremity(ies) , and/o r trunk , subsequen t orthotic(s)/prosthetic( s) encounter , ea ch 15 minutes

Y Age s 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t plus the firs t si x (6 ) visit s fo r Outpatien t settings. Ages 19 an d ove r do NO T require prior

authorizatio n fo r Physica l Therapy. I n Sout h Carolina , 97112 i s no t reimbursable to Physica l Therap y Providers. Prio r Authorizatio n request s wit h a Physica l Therapis t a s the

servicin g provide r wil l be denie d fo r 97112 Pregnan cy an d Deliver y 59400 Routine obstetri c care includin g antepartum care , vagina l deliver y

(wit h o r withou t episiotomy , and/o r forceps ) an d postpartum care NOTIFICATION Y Notificati on Only

Pregnan cy an d Deliver y 59409 Vagina l deliver y onl y (wit h o r withou t episiotom y and/o r forceps); NOTIFICATION Y Notificati on Only

Pregnan cy an d Deliver y 59410 Vagina l deliver y onl y (wit h o r withou t episiotom y and/o r forceps) ; includin g postpartum care

NOTIFICATION Y Notificati on Only

Pregnan cy an d Deliver y 59510 Routine obstetri c care includin g antepartum care , cesarean delivery , an d postpartum care


Pregnan cy an d Deliver y 59515 Cesarea n deliver y only ; includin g postpartum care NOTIFICATION Y Notificati on Only

Pregnan cy an d Deliver y 59610 Routine obstetri c care includin g antepartum care , vagina l deliver y (wit h o r withou t episiotomy , and/o r forceps ) an d postpartum care , afte r previous cesarea n delivery


Pregnan cy an d Deliver y 59612 Vagina l deliver y only , afte r previous cesarea n deliver y (wit h or withou t episiotom y and/o r forceps);


Pregnan cy an d Deliver y 59618 Routine obstetri c care includin g antepartum care , cesarean delivery , an d postpartum care , followin g attempte d vaginal deliver y afte r previous cesarea n delivery


Pregnan cy an d Deliver y 59620 Cesarea n deliver y only , followin g attempte d vagina l deliver y after previous cesarea n delivery;


Pregnan cy an d Deliver y 59622 Cesarea n deliver y only , followin g attempte d vagina l deliver y after previous cesarea n delivery ; includin g postpartum care


Prosthetics & Orthotics L0452 Tlso , flexible , provides trun k support , uppe r thoraci c region , produce s intracavitar y pressure to reduce loa d o n the intervertebra l disks wit h rigi d stays o r panel(s) , includes shoulder straps an d closure s, custom fabricated

Y

Prosthetics & Orthotics L0480 TLS O TRIPLANAR 1 PIECE W O INTERFCE LINER CST M Y Prosthetics & Orthotics L0482 TLS O TRIPLANAR 1 PIECE W INTERFCE LINER CST M

Y

Prosthetics & Orthotics L0484 TLS O TRIPLANAR 2 PIECE W O INTERFCE LINER CST M Y

Prosthetics & Orthotics L0486 TLS O TRIPLANAR 2 PIECE W INTERFCE LINER CST M Y Prosthetics & Orthotics L0622 SACROILIA C ORTHOTI C FLEXIBLE CUSTO M FABRICATED Y Prosthetics & Orthotics L0624 Sacroilia c orthoti c, provide s pelvic-sacra l support , wit h rigi d o r semi- Y Y Prosthetics & Orthotics L0626 Lumba r orthosi s, sagitta l control , wit h rigi d posterio r panel(s) , Y Y Prosthetics & Orthotics L0627 Lumba r orthosi s, sagitta l control , wit h rigi d anterio r an d posterior Y Y Prosthetics & Orthotics L0629 Lumbar-sacra l orthosis , flexible , provides lumbo-sacra l support , Y Y Prosthetics & Orthotics L0630 Lumbar-sacra l orthosis , sagitta l control , wit h rigi d posterior Y Y Prosthetics & Orthotics L0631 Lumbar-sacra l orthosis , sagitta l control , wit h rigi d anterio r and Y Y






Prosthetics & Orthotics L0632 Lumbar-sacra l orthosis , sagitta l control , wit h rigi d anterio r and posterio r panel s, posterio r extends from sacrococcygea l junctio n to t-9 vertebra , produce s intracavitar y pressure to reduce loa d o n the intervertebra l dis cs, include s strap s, closures , ma y include padding , shoulde r strap s, pendulous abdome n design , custom fabricated

Y Y

Prostheti cs & Orthotics L0634 Lumbar-sacra l orthosis , sagittal-corona l control , wit h rigi d posterior frame/panel(s) , posterio r extends from sacrococcygea l junctio n to t-9 vertebra , latera l strengt h provide d b y rigi d latera l frame/panel(s) , produces intracavitar y pressure to reduce loa d o n intervertebral discs , includes straps , closure s, ma y include padding , stay s, shoulde r strap s, pendulous abdome n design , custom fabricated

Y Y

Prosthetics & Orthotics L0636 Lumba r sacra l orthosis , sagittal-corona l control , lumba r flexion , rigi d posterio r frame/panels , latera l articulatin g desig n to fle x the lumba r spine , posterio r extends from sacrococcygea l junctio n to t-9 vertebra , latera l strengt h provide d b y rigi d latera l frame/panel s, produces intracavitar y pressure to reduce loa d o n intervertebral discs , includes straps , closure s, may include padding , anterior panel , pendulous abdome n design , custom fabricated

Y Y

Prosthetics & Orthotics L0637 LUMB-SACRA L ORTHOS SAG-COR CNT RL RIGD A AND P PREFAB Y

Prosthetics & Orthotics L0640 LS O SAGITTAL-CORONA L RIGID SHEL L PANE L CUST M FAB Y

Prosthetics & Orthotics L0650 LS O SAGITTAL-CORONA L CONT RL RIGD AN T POS T PANELS Y

Prosthetics & Orthotics L0700 CTLSO ANT-POSTERIOR-LA T CONTRO L MOLDED P T MODE L Y

Prosthetics & Orthotics L0710 CTLSO ANT-POST-LAT CNT RL MOLD PT-INTRFCE MAT L Y

Prosthetics & Orthotics L1000 CTLSO INCLUSIVE FURNISHING INI T ORTHOS INC L MD L Y






Prosthetics & Orthotics L1005 TENSIO N BASED SCOLIOSI S ORTHOTI C AND ACCESSORY PAD S Y

Prosthetics & Orthotics L1110 ADD CTLS O SCOLIO S RIN G FLNGE MOLD P T MD L Y Prosthetics & Orthotics L1640 HI P ORTHOTIC-PEL V BAND SPRDR BAR THI CUFF S FAB

Y Prosthetics & Orthotics L1680 HI P ORTHO T DY N PEL V CONTRO L THIGH CUF F CST M FAB Y Prosthetics & Orthotics L1685 HI P ORTHO S ABDC T CNT RL POSTO P HI P ABDC T CST M Y Prosthetics & Orthotics L1700 LEG G PERTHE S ORTHOTI C TORONT O CUSTO M FABRICATED Y Prosthetics & Orthotics L1710 LEG G PERTHE S ORTHOTI C NEWINGTO N CUSTO M FAB Y Prosthetics & Orthotics L1720 LEG G PERTHE S ORTHOTI C TRILA T TACHDIJA N CST M FAB Y Prosthetics & Orthotics L1730 LEG G PERTHE S ORTHOTI C SCOTTISH RITE CUSTO M FAB Y Prosthetics & Orthotics L1755 LEG G PERTHE S ORTHOTI C PATTE N BOTTO M CST M FAB Y Prosthetics & Orthotics L1834 K O WITHOU T KNEE JOIN T RIGID CUSTO M FABRICATED Y Prosthetics & Orthotics L1840 K O DEROTATIO N MEDIAL-LATERA L AC L CUSTO M FAB Y Prosthetics & Orthotics L1844 KNEE ORTHOSI S SINGLE UPRIGH T THIGH AND CAL F CUSTO M

Y Prosthetics & Orthotics L1846 KNEE ORTHOSI S DOUBLE UPRIGH T THIGH AND CAL F CUSTO M

Y Prosthetics & Orthotics L1860 KNEE ORTHO S MOD SUPRACONDYLR PRO S SOCK T CST M FAB Y Prosthetics & Orthotics L1900 AF O SPRN G WIRE DORSIFL X ASS T CAL F BAND CST M FAB Y Prosthetics & Orthotics L1904 ANKLE ORTH ANKLE GAUNTLE T SIMILAR CUSTO M FAB Y Prosthetics & Orthotics L1907 ANKLE ORTHOSI S SUPRAMALLEOLAR WITH STRAP S CUSTO M Y Prosthetics & Orthotics L1920 AF O SINGLE UP RT W STATI C ADJUSTB L STO P CST M FAB Y Prosthetics & Orthotics L1940 AN K F T ORTHOTI C PLASTI C OTH MATERIA L CUSTO M FAB

Y

Prosthetics & Orthotics L1945 AF O MOLD P T MD L PLST C RIGD AN T TIB L SEC T CST M

Y Prosthetics & Orthotics L1950 ANKLE FOO T ORTHOTI C SPIRA L PLASTI C CUSTOM-FAB Y Prosthetics & Orthotics L1960 AF O POSTERIOR SOLID AN K PLASTI C CUSTO M FAB Y Prosthetics & Orthotics L1970 AF O PLASTI C WITH ANKLE JOIN T CUSTO M FABRICATED Y Prosthetics & Orthotics L1980 AF O 1 UP RT FREE PLANTR DORSIFL X SOLID STIRU P FAB Y Prosthetics & Orthotics L1990 AF O DB L UP RT PLANTR DORSIFL X SOLID STIRU P CST M Y Prosthetics & Orthotics L2000 KAF O 1 UP RT FREE KNEE FREE AN K SOLID STIRU P CST M Y Prosthetics & Orthotics L2005 KAF O ANY MAT L AUT O LOC K AND SWN G RLSE W AN K JN T CST M Y Prosthetics & Orthotics L2006 Knee-ankle-foo t (KAF ) device , an y material , single o r double Y Prosthetics & Orthotics L2010 KAF O 1 UP RT SOLID STIRU P W O KNEE JN T CST M FAB

Y Prosthetics & Orthotics L2020 KAF O DB L UP RT SOLID STIRU P THI AND CAL F CST M FAB Y Prosthetics & Orthotics L2030 KAF O DB L UP RT SOLID STIRU P W O KNEE JN T CST M Y Prosthetics & Orthotics L2034 KAF O PLASTI C MED LA T ROTA T CNT RL CST M FAB

Y Prosthetics & Orthotics L2036 KAF O FUL L PLASTI C DOUBLE UPRIGH T CST M FAB Y

Prosthetics & Orthotics L2037 KAF O FUL L PLASTI C SINGLE UPRIGH T CUSTO M FAB Y Prosthetics & Orthotics L2038 KAF O FUL L PLASTI C MX-AXI S ANKLE CUSTO M FAB Y Prosthetics & Orthotics L2050 HKAF O TORSIO N CNT RL BI L TORSIO N CABLE S CST M FAB

Y

Prosthetics & Orthotics L2060 HKAF O TORSIO N CNT RL BI L TORSIO N BAL L BEAR CST M Y Prosthetics & Orthotics L2080 HKAF O TORSIO N CNT RL UNI TORSIO N CABLE CST M FAB Y Prosthetics & Orthotics L2090 HKAF O UNI TORSIO N CABLE BAL L BEAR CSTM Y Prosthetics & Orthotics L2106 AF O F X ORTHOTI C TIB F X CAS T THERMOPLST C CST M FAB Y Prosthetics & Orthotics L2108 AF O F X ORTHOTI C TIB F X CAS T ORTHOSI S CST M FAB Y Prosthetics & Orthotics L2126 KAF O FE M F X CAS T ORTHOTI C THERMOPLST C CST M FAB Y Prosthetics & Orthotics L2128 KAF O F X ORTHOTI C FE M F X CAS T ORTHOSI S CST M FAB Y Prosthetics & Orthotics L2232 ADD LOW EX T ORTHO S ROCKR BOTTO M TO T CNT C CST M

Y Prosthetics & Orthotics L2800 ADD LOW EX T ORTHO T KNEE CNT RL KNEE CA P CST M ONLY Y Prosthetics & Orthotics L4631 AF O WAL K BOO T TY P ROCKR BOTT M AN T TIB SHEL L CST M Y Prosthetics & Orthotics L5856 ADD LOW EX T PRO S KNEE-SHI N SY S SWIN G AND STANCE PHSE Y Prosthetics & Orthotics L5857 ADD LOW EX T PRO S KNEE-SHI N SY S SWIN G PHASE ONLY

Y Prosthetics & Orthotics L5858 ADD LW EX T PRO S KNEE SHI N SY S STANCE PHASE ONLY Y Prosthetics & Orthotics L5859 ADD LOW EX T PRO S KN-SHI N PRO G FL X EX T ANY MOTOR Y Prosthetics & Orthotics L6026 TRANSCARPA L M C PA RT HAND DISARTICULATIO N PRO S Y Prosthetics & Orthotics L7259 ELECTRONI C WRIS T ROTATOR ANY TYPE Y

Prosthetics & Orthotics L7700 GASKE T SEA L USE PRO S SOCKE T INSE RT ANY TYPE E A Y Prosthetics & Orthotics L8033 Nipple prosthesis , custom fabricated , reusable , an y material , an y Y Prosthetics & Orthotics L8614 COCHLEAR DEVICE INCLUDE S AL L IN T AND EX T COMPONENT S Y Prosthetics & Orthotics L8692 AUDITORY OSSEOINTEGRATED DE V EX T SOUND BODY WO RN Y Prosthetics & Orthotics L9900 Orthotic an d prosthetic supply , accessory , and/o r service

componen t o f anothe r hcp cs "l " code Y Y

Prosthetics & Orthotics S1040 CRANIA L REMOLDIN G ORTHOTI C PED RIGID CUSTO M FAB

Y Radiatio n Therap y & Radio Surgery 77520 PROTO N T X DELIVERY SIMPLE W O COMPENSATIO N Y Radiatio n Therap y & Radio Surgery 77522 PROTO N T X DELIVERY SIMPLE W COMPENSATIO N Y

Molina Healthcare o f Sout h Carolin a, Inc.





Radiatio n Therap y & Radio Surgery 77523 PROTO N T X DELIVERY INTERMEDIATE Y Radiatio n Therap y & Radio Surgery 77525 PROTO N T X DELIVERY COMPLE X Y Radiatio n Therap y & Radio Surgery 81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE Y Radiatio n Therap y & Radio Surgery 81503 ONC O (OVARIAN ) BIOCHEMICA L ASSAY FIVE PROTEIN S Y Radiatio n Therap y & Radio Surgery 81599 UNLISTED MULTIANALYTE ASSAY ALGORITHMI C ANALYSI S Y Radiatio n Therap y & Radio Surgery A9513 LUTETIU M LU 177 DOTATATE THERAPEUTI C 1 MCI Y Radiatio n Therap y & Radio Surgery A9543 YTTRIU M Y-90 IBRITUMOMAB TIUXETA N T X T O 40 MCI Y Radiatio n Therap y & Radio Surgery A9590 Iodine I-131 , iobenguane , 1 mCi Y Radiatio n Therap y & Radio Surgery A9606 Radium RA-223 dichloride , therapeuti c, pe r mcCi Y Radiatio n Therap y & Radio Surgery G0339 IMAGE GUID ROBOTI C ACCE L BASE S RS CMP L T X 1 SES S Y Radiatio n Therap y & Radio Surgery G0340 IMAGE GUID ROBOTI C ACC L S RS FRA C T X LE S 2-5 SES S Y Radiatio n Therap y & Radio Surgery G6015 INTENSITY MODULATED T X DE L 1 M X FLD S PER T X SES S Y

Radiatio n Therap y & Radio Surgery G6016 COMP-BASED BEA M MOD T X DE L I PLND T X 3 OVER HR SES S Y Radiatio n Therap y & Radio Surgery G6017 Intra-fractio n localizatio n an d trackin g o f targe t o r patien t motion Y

Slee p Studies 95801 SL P STDY UNATND W MI N H RT RATE O2 SA T RES P ANA L Y Home Slee p Studies (PO S 12 ) Do No t Require PA Slee p Studies 95805 ML T SLEE P LATENCY MAIN T O F WAKEFULNES S TST G Y Home Slee p Studies (PO S 12 ) Do No t Require PA Slee p Studies 95806 SLEE P STD AIRFLOW H RT RATE AND O2 SA T EFFO RT UNAT T Y Home Slee p Studies (PO S 12 ) Do No t Require PA Slee p Studies 95807 SLEE P STD RE C VNT J RESPIR EC G H RT RATE AND O2 ATT N Y Home Slee p Studies (PO S 12 ) Do No t Require PA Slee p Studies 95808 POLYSO M ANY AGE SLEE P STAGE 1-3 ADD L PARA M ATTND Y Home Slee p Studies (PO S 12 ) Do No t Require PA Slee p Studies 95810 POLYSO M 6 OR G RT YRS SLEE P 4 OR G RT ADD L PARA M ATTND Y Home Slee p Studies (PO S 12 ) Do No t Require PA

Slee p Studies 95811 POLYSO M 6 OR G RT Y RS SLEE P W CPA P 4 OR G RT ADD L PARA M AT T Y Home Slee p Studies (PO S 12 ) Do No t Require PA

Spee ch Therapy 92507 T X SPEECH LAN G VOICE COMM J AND AUDITORY PRO C IND Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visi t for Outpatien t settings. Ages 19 an d ove r do NO T require prio r authorizatio n fo r Speech Therapy. I n Sout h Carolina , 97112 is no t reimbursable to Spee ch Therap y Providers.

Spee ch Therapy 92508 T X SPEECH LANGUAGE VOICE COMM J AUDITRY 2 OR G RT INDIV Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visit for Outpatien t settings. Ages 19 an d ove r do NO T require prio r authorizatio n fo r Speech Therapy. I n Sout h Carolina , 97112 is no t reimbursable to Spee ch Therapy Providers.

Spee ch Therapy 92526 Treatmen t o f swallowin g dysfunctio n and/o r ora l functio n for feeding

Y Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visit for Outpatient settings. Ages 19 an d ove r do NO T require prio r authorizatio n fo r Speech Therapy. I n Sout h Carolina , 97112 is not reimbursable to Spee ch Therapy Providers.

Spee ch Therapy 92606 Therapeutic service(s) fo r the use o f non-speech-generating device,including programming an d modification

Y Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visit for Outpatient settings. Ages 19 an d ove r do NO T require prio r authorizatio n fo r Speech Therapy. I n Sout h Carolina, 97112 is not reimbursable to Spee ch Therapy Providers.

Spee ch Therapy 92609 Therapeutic services fo r the use o f speech-generating device, including programming an d modification

Y Y Ages 18 an d younge r require prio r authorizatio n afte r the initia l evaluation/visit for Outpatient settings. Ages 19 an d ove r do NO T require prio r authorizatio n fo r Speech Therapy. I n Sout h Carolina, 97112 is not reimbursable to Spee ch Therapy Providers.

Transplants/Gene Therapy 32851 Lun g transplant , single ; withou t cardiopulmonar y bypass Y Cornea l Transplants do no t require Prio r Authorization Transplants/Gene Therapy 32852 Lun g transplant , single ; wit h cardiopulmonar y bypass Y Cornea l Transplants do no t require Prio r Authorization Transplants/Gene Therapy 32853 LUN G TRANSPLAN T 2 W O CARDIOPULMONARY BYPASS Y

Transplants/Gene Therapy 32853 Lun g transplant , double (bilatera l sequentia l o r e n bloc) ; withou t Y Cornea l Transplants do no t require Prio r Authorization Transplants/Gene Therapy 32854 Lun g transplant , double (bilatera l sequentia l o r e n bloc) ; with

cardiopulmonar y bypass Y Cornea l Transplants do no t require Prio r Authorization

Transplants/Gene Therapy 32855 Backben ch standar d preparatio n o f cadave r dono r lun g allograf t prio r to transplantation , includin g dissectio n o f allograf t from surroundin g sof t tissues to prepare pulmonar y venous/atria l cuff , pulmonar y artery , an d bronchu s; unilateral

Y Cornea l Transplants do no t require Prio r Authorization

Transplants/Gene Therapy 32856 Backben ch standar d preparatio n o f cadave r dono r lun g allograf t prio r to transplantation , includin g dissectio n o f allograf t from

Y Cornea l Transplants do no t require Prio r Authorization

Transplants/Gene Therapy 33930 Dono r cardiectomy-pneumonectom y (includin g col d preservation) Y Cornea l Transplant s do no t require Prio r Authorization

olina Healthcare o f Sout h Carolin a, Inc. M





Transplants/Gene Therapy 33933 Backben ch standar d preparatio n o f cadave r dono r heart/lun g allograf t prio r to transplantation , includin g dissectio n o f allograf t from surroundin g sof t tissues to prepare aorta , superio r ven a cava , inferio r ven a cava , an d trache a fo r implantation

Y Corneal Transplants do not require Prior Authorization

Transplants/Gene Therapy 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy Y Corneal Transplants do not require Prior Authorization

Transplants/Gene Therapy 33940 Donor cardiectomy (including cold preservation) Y Corneal Transplants do not require Prior Authorization

Transplants/Gene Therapy 33944 Backben ch standar d preparatio n o f cadave r dono r hear t allograf t prio r to transplantation , including dissectio n o f allograf t from surroundin g sof t tissues to prepare aorta , superio r ven a cava , inferio r ven a cava , pulmonar y artery , an d lef t atrium for implantation

Y Corneal Transplants do not require Prior Authorization

Transplants/Gene Therapy 33945 Heart transplant, with or without recipient cardiectomy Y Corneal Transplants do not require Prior Authorization

Transplants/Gene Therapy 38205 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 38206 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL Y Corneal Transplants do not require Prior Authorization

Transplants/Gene Therapy 38230 BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 38240 TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 38241 TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 38242 ALLOGENEIC LYMPHOCYTE INFUSIONS Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 38243 TRNSPLJ HEMATOPOIETIC CELL BOOST Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44132 DONOR ENTERECTOMY OPEN CADAVER DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44133 DONOR ENTERECTOMY OPEN LIVING DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44135 INTESTINAL ALLOTRANSPLANTATION; CADAVER DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44136 INTESTINAL ALLOTRANSPLANTATION; LIVING DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44137 RMVL TRNSPLED INTESTINAL ALLOGRAFT COMPL Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44715 BKBENCH PREP CADAVER LIVING DONOR INTESTINE Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44720 BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 44721 BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47133 DONOR HEPATECTOMY CADAVER DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47135 LVR ALTRNSPLJ ORTHOTOPIC PRTL WHL DON ANY AGE Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47140 DONOR HEPATECTOMY LIVING DONOR SEG II AND III Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47141 DONOR HEPATECTOMY LIVING DONOR SEG II III AND IV Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47142 DONOR HEPATECTOMY LIVING DONOR SEG V VI VII AND VI Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47143 BKBENCH PREP CADAVER DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47144 BKBENCH PREPJ CADAVER WHOLE LIVER GRF I AND IV VII Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47145 BKBENCH PREPJ CADAVER DONOR WHL LVR GRF I AND V VI Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47146 BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 47147 BKBENCH RCNSTJ LVR GRF ARTL ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 48160 PANCREATECTOMY W TRNSPLJ PANCREAS ISLET CELLS Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 48550 DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 48551 BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 48552 BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 48554 TRANSPLANTATION PANCREATIC ALLOGRAFT Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 48556 RMVL TRANSPLANTED PANCREATIC ALLOGRAFT Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50300 DONOR NEPHRECTOMY CADAVER DONOR UNI BILATERAL Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50320 DONOR NEPHRECTOMY OPEN LIVING DONOR Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50323 BKBENCH PREPJ CADAVER DONOR RENAL ALLOGRAFT Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50325 BKBENCH PREPJ LIVING RENAL DONOR ALLOGRAFT Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50327 BKBENCH RCNSTJ RENAL ALGRFT VENOUS ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50328 BKBENCH RCNSTJ RENAL ALLOGRAFT ARTERIAL ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50329 BKBENCH RCNSTJ ALGRFT URETERAL ANAST EA Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50340 RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50360 RENAL ALTRNSPLJ IMPLTJ GRF W O RCP NEPHRECTOMY Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50365 RENAL ALTRNSPLJ IMPLTJ GRF W RCP NEPHRECTOMY Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50370 RMVL TRNSPLED RENAL ALLOGRAFT Y Corneal Transplants do not require Prior Authorization Transplants/Gene Therapy 50380 RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY Y Corneal Transplants do not require Prior Authorization




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Unlisted/Miscellaneous codes 21899 UNLISTED PROCEDURE NECK THORAX Y Molin a requires PA , as wel l as medica l necessit y documentatio n an d rationale be submitte d wit h the P A reque st fo r AL L unlisted/miscellaneous codes ; includin g those no t

liste d herein. Unlisted/Miscellaneous codes 22899 UNLISTED PROCEDURE SPINE Y Molina requires PA, as well as medical necessity documentation and rationale be

submitted with the PA request for ALL unlisted/miscellaneous codes; including those not listed herein.

Unlisted/Miscellaneous codes 22999 UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 23929 UNLISTED PROCEDURE SHOULDER Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 24999 UNLISTED PROCEDURE HUMERUS ELBOW Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 25999 UNLISTED PROCEDURE FOREARM WRIST Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 26989 UNLISTED PROCEDURE HANDS FINGERS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 27299 UNLISTED PROCEDURE PELVIS HIP JOINT Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 27599 UNLISTED PROCEDURE FEMUR KNEE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 27899 UNLISTED PROCEDURE LEG ANKLE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 28899 UNLISTED PROCEDURE FOOT TOES Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 29999 UNLISTED PROCEDURE ARTHROSCOPY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 30999 UNLISTED PROCEDURE NOSE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 31299 UNLISTED PROCEDURE ACCESSORY SINUSES Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 31599 UNLISTED PROCEDURE LARYNX Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 31899 UNLISTED PROCEDURE TRACHEA BRONCHI Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 32999 UNLISTED PROCEDURE LUNGS AND PLEURA Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 33999 UNLISTED CARDIAC SURGERY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 36299 UNLISTED PROCEDURE VASCULAR INJECTION Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 37501 UNLISTED VASCULAR ENDOSCOPY PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 37799 UNLISTED PROCEDURE VASCULAR SURGERY Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes 38129 UNLISTED LAPAROSCOPY PROCEDURE SPLEE N Y Molin a requires PA , as wel l as medica l necessit y documentatio n an d rationale be submitte d wit h the P A reque st fo r AL L unlisted/miscellaneous codes ; includin g those no t

liste d herein. Unlisted/Miscellaneous codes 38589 UNLISTED LAPAROSCOPY PX LYMPHATIC SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 38999 UNLISTED PROCEDURE HEMIC OR LYMPHATIC SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 39499 UNLISTED PROCEDURE MEDIASTINUM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 39599 UNLISTED PROCEDURE DIAPHRAGM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 40799 UNLISTED PROCEDURE LIPS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 40899 UNLISTED PROCEDURE VESTIBULE MOUTH Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 41599 UNLISTED PROCEDURE TONGUE FLOOR MOUTH Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 42299 UNLISTED PROCEDURE PALATE UVULA Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 42699 UNLISTED PX SALIVARY GLANDS DUCTS Y Molina requires PA, as well as medical necessity documentation and rationale be

submitted with the PA request for ALL unlisted/miscellaneous codes; including those not liste d herein.

Unlisted/Miscellaneous codes 42999 UNLISTED PROCEDURE PHARYNX ADENOIDS TONSILS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 43289 UNLISTED LAPAROSCOPIC PROCEDURE ESOPHAGUS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 43499 UNLISTED PROCEDURE ESOPHAGUS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 43659 UNLISTED LAPAROSCOPIC PROCEDURE STOMACH Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 43999 UNLISTED PROCEDURE STOMACH Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 44238 UNLISTED LAPAROSCOPY PX INTESTINE XCP RECTUM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 44799 UNLISTED PROCEDURE SMALL INTESTINE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 44899 UNLISTED PX MECKEL'S DIVERTICULUM AND MESENTERY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 44979 UNLISTED LAPAROSCOPY PROCEDURE APPENDIX Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 45399 UNLISTED PROCEDURE COLON Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 45499 UNLISTED LAPAROSCOPY PROCEDURE RECTUM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes 45999 UNLISTED PROCEDURE RECTUM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 46999 UNLISTED PROCEDURE ANUS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 47379 UNLIS LAPAROSCOPIC PROCEDURE LIVER Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 47399 UNLISTED PROCEDURE LIVER Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 47579 UNLISTED LAPAROSCOPY PROCEDURE BILIARY TRACT Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 47999 UNLISTED PROCEDURE BILIARY TRACT Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 48999 UNLISTED PROCEDURE PANCREAS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 49329 UNLISTED LAPAROSCOPIC PX ABD PERTONEUM AND OMENTUM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 49659 UNLIS LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 49999 UNLISTED PROCEDURE ABDOMEN PERITONEUM AND OMENTUM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 50549 UNLISTED LAPAROSCOPY PROCEDURE RENAL Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 50949 UNLISTED LAPAROSCOPY PROCEDURE URETER Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 51999 UNLISTED LAPAROSCOPY PROCEDURE BLADDER Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 53899 UNLISTED PROCEDURE URINARY SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 54699 UNLISTED LAPAROSCOPY PROCEDURE TESTIS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 55559 UNLISTED LAPROSCOPY PROCEDURE SPERMATIC CORD Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 55899 UNLISTED PROCEDURE MALE GENITAL SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 58578 UNLISTED LAPAROSCOPY PROCEDURE UTERUS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 58579 UNLISTED HYSTEROSCOPY PROCEDURE UTERUS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 58679 UNLISTED LAPAROSCOPY PROCEDURE OVIDUCT OVARY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 58999 UNLISTED PX FEMALE GENITAL SYSTEM NONOBSTETRICAL Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes 59897 UNLISTED FETA L INVASIVE P X W ULTRASOUND Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

liste d herein. Unlisted/Miscellaneous codes 59898 UNLISTED LAPAROSCOPY PX MATERNITY CARE AND DELIVERY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 59899 UNLISTED PROCEDURE MATERNITY CARE AND DELIVERY Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 60659 UNLISTED LAPAROSCOPY PROCEDURE ENDOCRINE SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 60699 UNLISTED PROCEDURE ENDOCRINE SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 64999 UNLISTED PROCEDURE NERVOUS SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 66999 UNLISTED PROCEDURE ANTERIOR SEGMENT EYE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 67299 UNLISTED PROCEDURE POSTERIOR SEGMENT Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 67399 UNLISTED PROCEDURE EXTRAOCULAR MUSCLE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 67599 UNLISTED PROCEDURE ORBIT Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 67999 UNLISTED PROCEDURE EYELIDS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 68399 UNLISTED PROCEDURE CONJUNCTIVA Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 68899 UNLISTED PROCEDURE LACRIMAL SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 69399 UNLISTED PROCEDURE EXTERNAL EAR Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 69799 UNLISTED PROCEDURE MIDDLE EAR Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 69949 UNLISTED PROCEDURE INNER EAR Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 69979 UNLISTED PROCEDURE TEMPORAL BONE MIDDLE FOSSA Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 76496 UNLISTED FLUOROSCOPIC PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 76499 UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 77299 Unlisted procedure, therapeutic radiology clinical treatment

planning Y Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 77399 UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes 77499 Unlisted procedure, therapeutic radiology treatment management Y Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 77799 UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 78099 UNLISTED ENDOCRINE PX DX NUCLEAR MEDICINE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 78199 UNLIS HEMATOP RET ENDO AND LYMPHATIC DX NUC MED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 78299 UNLISTED GASTROINTESTINAL PX DX NUCLEAR MEDICINE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 78399 UNLISTED MUSCULOSKELETAL PX DX NUCLEAR MEDICINE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 78599 UNLISTED RESPIRATORY PX DX NUCLEAR MEDICINE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 78699 UNLISTED NERVOUS SYSTEM PX DX NUCLEAR MEDICINE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 78799 UNLISTED GENITOURINARY PX DX NUCLEAR MEDICINE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 78999 UNLISTED MISCELLANEOUS PX DX NUCLEAR MEDICINE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 79999 RP THERAPY UNLISTED PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 80299 QUANTITATION DRUG NOT ELSEWHERE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 81099 UNLISTED URINALYSIS PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 85999 UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 86486 SKIN TEST UNLISTED ANTIGEN EACH Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 86849 UNLISTED IMMUNOLOGY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 86999 UNLISTED TRANSFUSION MEDICINE PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 87797 IADNA NOS DIRECT PROBE TQ EACH ORGANISM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 87798 IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 87799 IADNA NOS QUANTIFICATION EACH ORGANISM Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 87899 IAADIADOO NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes 87999 UNLISTED MICROBIOLOGY Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request fo r AL L unlisted/miscellaneous codes; including those not

liste d herein. Unlisted/Miscellaneous codes 88099 UNLISTED NECROPSY PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 88199 UNLISTED CYTOPATHOLOGY PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 88299 UNLISTED CYTOGENETIC STUDY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 88399 UNLISTED SURGICAL PATHOLOGY PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 88749 UNLISTED IN VIVO LABORTORY SERVICE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 89240 UNLIS MISC PATH Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 89398 UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 90399 UNLISTED IMMUNE GLOBULIN Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 90749 UNLISTED VACCINE TOXOID Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 90899 UNLISTED PSYCHIATRIC SERVICE PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 91299 UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 92499 UNLISTED OPHTHALMOLOGICAL SERVICE PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 92700 UNLISTED OTORHINOLARYNGOLOGICAL SERVICE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 93799 UNLISTED CARDIOVASCULAR SERVICE PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 94799 UNLISTED PULMONARY SERVICE PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 95199 UNLISTED ALLERGY CLINICAL IMMUNOLOGIC SRVC PX Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 95999 UNLIS NEUROLOGICAL NEUROMUSCULAR DX PX Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 96379 UNLISTED THERAPEUTIC PROPH DX IV IA NJX NFS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 96549 UNLISTED CHEMOTHERAPY PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 96999 UNLISTED SPECIAL DERMATOLOGICAL SERVICE PROCED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes 97039 UNLIST MODALITY SPEC TYPE AND TIME CONSTANT ATTEND Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 97139 UNLISTED THERAPEUTIC PROCEDURE SPECIFY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 97799 UNLISTED PHYSICAL MEDICINE REHAB SERVICE PROC Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 99199 UNLISTED SPECIAL SERVICE PROCEDURE REPORT Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 99429 UNLISTED PREVENTIVE MEDICINE SERVICE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 99499 UNLISTED EVALUATION AND MANAGEMENT SERVICE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes 99600 UNLISTED HOME VISIT SERVICE PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes 01999 UNLISTED ANESTHESIA PROCEDURE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes A0999 UNLISTED AMBULANCE SERVICE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes A4421 OSTOMY SUPPLY; MISCELLANEOUS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes A4641 RADIOPHARMACEUTICAL DIAGNOSTIC NOC Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes A4649 SURGICAL SUPPLY; MISCELLANEOUS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes A4913 MISCELLANEOUS DIALYSIS SUPPLIES NOS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes A6261 WOUND FILLER GEL PASTE PER FL OZ NOS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes A6262 WOUND FILLER DRY FORM PER G NOT OTHERWISE SPEC Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes A9698 NON-RADIOACTV CONTRST IMAG MATERIAL NOC PER STDY Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes A9699 RADIOPHARMACEUTICAL THERAPEUTIC NOC Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes A9900 DME SUP ACCESS SRV-COMPON OTH HCPCS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes A9999 MISCELLANEOUS DME SUPPLY OR ACCESSORY NOS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes B9998 NOC FOR ENTERAL SUPPLIES Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes B9999 NOC FOR PARENTERAL SUPPLIES Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes C1889 Implantable/insertable device , no t otherwise classified Y Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

liste d herein. Unlisted/Miscellaneous codes C2698 BRACHYTHERAPY SOURCE STRANDED NOS PER SOURCE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes C2699 BRACHYTHERAPY SOURCE NONSTRANDED NOS PER SOURCE Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes E0769 ESTIM ELECTROMAGNETIC WOUND TREATMENT DEVC NOC Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes E0770 FES TRANSQ STIM NERV AND MUSC GRP CMPL SYS NOS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes E1399 DURABLE MEDICAL EQUIPMENT MISCELLANEOUS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes E1699 DIALYSIS EQUIPMENT NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes G0501 RESOURCE-INT SRVC PT SPZ M-ASST TECH MED NEC Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes G9012 OTHER SPECIFIED CASE MANAGEMENT SERVICE NEC Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes J7599 IMMUNOSUPPRESSIVE DRUG NOT OTHERWISE CLASSIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes J7699 NOC DRUGS INHALATION SOLUTION ADMINED THRU DME Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes J7799 NOC RX OTH THAN INHALATION RX ADMINED THRU DME Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes J7999 COMPOUNDED DRUG NOT OTHERWISE CLASSIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes J8498 ANTIEMETIC DRUG RECTAL SUPPOSITORY NOS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes J8597 ANTIEMETIC DRUG ORAL NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes K0812 POWER OPERATED VEHICLE NOT OTHERWISE CLASSIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes K0898 POWER WHEELCHAIR NOT OTHERWISE CLASSIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes K0899 PWR MOBILTY DVC NOT CODED DME PDAC NOT MEET CRIT Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes L0999 ADD TO SPINAL ORTHOTIC NOT OTHERWISE SPECFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes L1499 SPINAL ORTHOTIC NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes L2999 LOWER EXTREMITY ORTHOSES NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes L3649 ORTHOPED SHOE MODIFICATION ADDITION TRANSFER NOS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes L3999 UPPER LIMB ORTHOSIS NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes L5999 LOWER EXTREMITY PROSTHESIS NOS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes L7499 UPPER EXTREMITY PROSTHESIS NOS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes L8039 BREAST PROSTHESIS NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes L8499 UNLISTED PROC MISCELLANEOUS PROSTHETIC SERVICES Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes L8698 MISC COMP SPL ACCESS FOR USE WITH TOT AH SYSTEM Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes L8699 PROSTHETIC IMPLANT NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes L8701 PWR UE ROM AST DVC ELB WR HAND 1 DBL UP CUS FAB Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes L8702 PWR UE ROM AST DVC ELBO WR H FINGER 1 DBL UP CUS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes P9099 Blood component or product not otherwise classified Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes P9603 TRAVEL 1 WAY MED NEC LAB SPEC; PRORAT ACTL MILE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes P9604 TRAVEL 1 WAY MED NEC LAB SPEC; PRORATD TRIP CHRG Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes Q0507 MISC SUPPLY OR ACCESSORY USE WITH EXTERNAL VAD Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes Q0508 MISC SUPPLY OR ACCESSORY USE WITH IMPLANTED VAD Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes Q0509 MISC SPL ACSS IMPL VAD NO PAYMENT MEDICARE PRT A Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes Q2039 INFLUENZA VIRUS VACCINE NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes Q4050 CAST SUPPLIES UNLISTED TYPES AND MATERIALS OF CASTS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes Q4051 SPLINT SUPPLIES MISCELLANEOUS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes Q4082 DRUG OR BIOLOGICAL NOC PART B DRUG CAP Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes Q4100 SKIN SUBSTITUTE NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.






Unlisted/Miscellaneous codes S0590 INTEGRA L LEN S SERVICE MIS C SERVICE S REPORTED SE P Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

liste d herein. Unlisted/Miscellaneous codes S8189 TRACHEOSTOMY SUPPLY NOT OTHERWISE CLASSIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes S9110 TELEMONITORING PT HOME ALL NEC EQUIP; PER MONTH Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes T1999 MISC TX ITEMS AND SPL RETAIL PURCHASE NOC Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes T2025 WAIVER SERVICES; NOT OTHERWISE SPECIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes V2199 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes V2399 Specialty trifocal (by report) Y Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes V2797 VISN SPL ACSS AND SRVC CMPNT ANOTHER HCPCS CODE Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes V2799 VISION ITEM OR SERVICE MISCELLANEOUS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein. Unlisted/Miscellaneous codes V5298 HEARING AID NOT OTHERWISE CLASSIFIED Y Molina requires PA, as well as medical necessity documentation and rationale be


Unlisted/Miscellaneous codes V5299 HEARING SERVICE MISCELLANEOUS Y Molina requires PA, as well as medical necessity documentation and rationale be submitted with the PA request for ALL unlisted/miscellaneous codes; including those not

listed herein.

Molina Healthcare o f Sout h Carolin a, Inc.

Medicai d Prio r Authorizatio n Matrix

Q4 , Ef f Octobe r 1 , 2020 92

Documents

Medicaid Prior Authorization (PA) Code Matrix · H0015: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week