Medicare Advantage - Healthx

Code: Description: Effective Date: Who to Contact for Review:104 Anesthesia for electroconvulsive therapy Optum Behavioral Health

Optum provider portal

844-884-185500731 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not

otherwise specified

10-16-2018 Premera Blue Cross

Provider Portal

855-339-812700732 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum;

endoscopic retrograde

cholangiopancreatography (ERCP)


Provider Portal

855-339-8127

00811 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise

specified


Provider Portal

855-339-812700812 Anesthesia for lower intestinal endoscopic 10-16-2018 Premera Blue Cross

Provider Portal

855-339-812700813 Anesthesia for lower intestinal endoscopic 10-16-2018 Premera Blue Cross

Provider Portal

855-339-812711920 Tattoo/Color Defect to 6.0 Sq Cm 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812711921 Tattooing 6-20 Sq Cm 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812711922 Tattoo/Color Defect Ea Add 20 Sq Cm 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

Medicare Advantage

On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a guarantee of payment. Benefits are based on eligibility at the time of service and are

subject to applicable contract terms.

Note: We display one prior authorization list for all MA plans, but there are a few instances where we have different requirements for some of our plans.

• We recommend you review this list before you submit your requests.

• CPT codes with an asterisk (*) may be processed reviewed for prior authorization by either Optum Behavioral Health or Visiant UM,

depending based on the members diagnosis.

• CPT codes with a plus symbol (†) are for drugs that have prior authorization overlap with Part D formulary.

• CPT codes with a double plus symbol (‡) indicate prior authorization required only for members with one of the following plan benefit packages:

HMO; Classic; ClassicPlus; Core; or Total Health. Prior authorization of these codes is not required for Premera MA members on other plan benefit

packages.

• This serves as the prior authorization list for CMS plan numbers: H7245 & H9302.

https://www.providerexpress.com/content/ope-provexpr/us/en.html



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Code: Description: Effective Date: Who to Contact for Review:15002 Surgical Preparation or Creation of Recipient Site, T/A/L; 1st 100 Sq Cm or 1% of Body Area of Infants and Children 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715003 Surgical Preparation or Creation of Recipient Site, T/A/L; Ea Addl 100 Sq Cm or Ea Addl 1% of Body Area Infant/Child 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715004 Surgical Preparation or Creation of Recipient Site, F/S/E/M/N/E/O/G/H/F/D; 1st 100 Sq Cm or 1% of Body Area

Infant/Child


Provider Portal

855-339-812715005 Surg Preparation or Creation of Recipient Site, F/S/E/M/N/E/O/G/H/F/D; Ea Addl 100 Sq Cm or 1% Of Body Area

Infant/Child


Provider Portal

855-339-812715271 Skin Subst Graft To Trunk, Arms, Legs, Area Up To 100 Sq Cm; First 25 Sq Cm Or Less Wound Surface Area 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715272 Skin Subst Graft To Trunk, Arms, Legs, Area Up To 100 Sq Cm; Ea Additional 25 Sq Cm Wound Service Area, Or Part

Thereof


Provider Portal

855-339-812715273 Skin Subst Graft To Trunk, Arms, Legs, Area >/= 100 Sq Cm; 1St 100 Sq Cm Or 1% Of Body Area Of Infants And

Children


Provider Portal

855-339-812715274 Skin Subst Graft To Trunk, Arms, Legs, Area >/= 100 Sq Cm; Ea Addl 100 Sq Cm Or Ea Adl 1% Of Body Area Of

Inf&Children


Provider Portal

855-339-812715275 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area Up To 100 Sq Cm; 1St 25 Sq Cm Or Less Wound Surface Area 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715276 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area Up To 100 Sq Cm; 1St 25 Sq Cm Or Less Wound Surface Area 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715277 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area >/= 100 Sq Cm; 1St 100 Sq Cm Or 1% Of Body Area Of Infants

And Children


Provider Portal

855-339-812715278 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area >/= 100 Sq Cm; Ea Addl 100 Sq Cm Or 1% Of Body Area Of

Infants And Children


Provider Portal

855-339-812715820 Blepharoplasty Lower Eyelids 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715821 Blepharoplasty W Extensive Fat Pads 05-01-2018 Premera Blue Cross

Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:15822 Blepharoplasty Upper Eyelid 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715823 Rhytidectomy W Excess Skin On Lids 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715830 Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy); Abdomen, Infraumbilical Panniculectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715832 Exc Excess Skin Subq Tiss Thigh 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715833 Exc Excess Skin Leg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715834 Exc Excess Skin Subq Tiss Hip 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715835 Exc Excess Skin Buttock 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715836 Exc Excess Skin Subq Tiss Arm 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715837 Exc Excess Skin Forearm 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715838 Exc Excess Skin Subq Tiss Fat Pad 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715839 Exc Excess Skin Other Area 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812715847 Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy), Abdomen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812717106 Dest Cut Vasc Proliferative Les to 10 Sq 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812717107 Dest Cut Vasc Prolif Les 10-50 Sq cm 05-01-2018 Premera Blue Cross

Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:17108 Dest Cut Vasc Proliferative Les Over 50. 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719296 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial

radioelement application following partial mastectomy, includes image guidance

01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077619297 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial

radioelement application following partial mastectomy, includes image guidance


AIM Provider Portal

866-666-077619298 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for

interstitial radioelement application following partial mastectomy, includes image guidance


AIM Provider Portal

866-666-077619300 Mastectomy for gynecomastia 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719316 Mastopexy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719318 Mammoplasty Reduction 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719324 Mammaplasty Augment Wo/Prosthetic Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719325 Mammoplasty Augmentation W Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719328 Removal of Intact Mammary Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719330 Removal Mammary Implant Unilateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719340 Insert Breast Prosthesis Immediate 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719342 Delay Insert Prosthesis Mast/Recons 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719350 Reconstruct Nipple/Areolar Unil 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

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Code: Description: Effective Date: Who to Contact for Review:19355 Correction Inverted Nipple(S) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719357 Breast Recon W/Tiss Expander Inc Expansion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719361 Breast Recon Latissimus Dorsi Flap W/Wo 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719364 Breast Reconstruction W/Free Flap 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719366 Reconstruction Breast Other Method 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719367 Breast Reconstn W Trans Rectus Abdominis Musc Flap (Tram), SGL Pedicle 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719368 Breast Reconstn, Trans Rect Abd Musc Flap (Tram), SGL Ped; Mic Anast 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719369 Breast Reconstn W Trans Rectus Abdominis Musc Flap (Tram), DBL Pedicle 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719370 Open Periprosthetic Capsulotomy Breast 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719371 Capsulectomy Periprosthetic Breast 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719380 Revision Reconstructed Breast 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812719396 Preparation Moulage Breast Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812720555 Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement

application (at the time of or subsequent to the procedure)


AIM Provider Portal

866-666-077620930 Allograft for Spine Surgery; Morselized 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127










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Code: Description: Effective Date: Who to Contact for Review:20937 Autograft for Spine Surgery; Morselized 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812720974 Stimulate Bone Electric Noninvasive 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812720975 Electrical Stim Aid Bone Heal Invasive 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812720979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721070 Coronoidectomy Unilateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721077 Impression and Custom Preparation; Orbital Prosthesis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721081 Impress/Prep Mandibular Resection 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721082 Impress Custom Prep Palatal Augmentation 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721083 Impress/Prep Palatal Lift Prosth 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721085 Impress/Prep Oral Surgical Splint 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721086 Impress Custom Prep Auricular Prosth 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721087 Impress/Prep Nasal Prosth 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721088 Impress Custom Prep Facial Prosth 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721110 Apply Interdental Fixation Other 05-01-2018 Premera Blue Cross

Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:21121 Genioplasty Sliding Osteotomy Single Pie 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721122 Genioplasty Slide Osteotomy 2+ 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721123 Genioplasty Sliding Augmentation W/Bone 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721141 Reconstruction Midface, Single Piece 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721142 Reconstruction Midface, Two Pieces 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721143 Reconstruction Midface, Three or More Pieces 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721145 Recon Midface Lefort I Single Graft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721146 Recon Midface Lefort I 2 Piece W/Bone Gr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721147 Recon Midface Lefort I 3+ Pcs Graft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721150 Recon Midface Lefort II Anterior Intrusi 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721151 Recon Midface Lefort II W/Bone Grft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721154 Recon Midface Lefort III w/o Lefort I 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721155 Recon Midface Lefort III w/ Lefort I 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

21159 Recon Midface Lefort III w/Graft; w/o Lefort l 05-01-2018 Premera Blue Cross

Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:21160 Recon Midface Lefort III w/Grft; w/Lefort l 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

21196 Recon Mand Ramus Sag Split W/Rigid Rix 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721198 Osteotomy Mandible Segmental 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721199 Osteotomy, Mandible, Segmental; with Genioglossus Advancement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721206 Osteotomy Maxilla Segmental 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721208 Osteoplasty Facial Bone Augment 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721209 Osteoplasty Facial Reduction 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721210 Graft Bone Nasal Maxilla Malar Area 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721215 Graft Bone Mandible 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721230 Graft Rib Cart to Face Chin Nose Ear 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721244 Reconstruct Mandible W Bone Plate 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721245 Recon Mand Max Subperiosteal Part 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721246 Repair Jaw W Subperiost Implnt Tot 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721247 Recon Mand Condyle Bone Cart Auto 05-01-2018 Premera Blue Cross

Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:21248 Recon Mandible Maxilla Endosteal Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721249 Repair Jaw W Endosteal Implnt Tot 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721256 Recon Orbit W/ Osteotomies/Bone Grft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721260 Periorbital Osteotomy W/Graft Extracrani 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721261 Rep Orbit Hypertelorism Combin Appr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721263 Periorbital Osteotomy W/Graft Forehead A 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721267 Reposition Orbit Unil Extracranial 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721267 Reposition Orbit Unil Extracranial 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721268 Orbit Reposition Unilat W/Graft Intra/Ex 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721275 2ndary Revision Orbitocraniofacial Recon 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721685 Hyoid Myotomy and Suspension 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721740 Recon Rep Pectus Excava/Carinatum 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812721742 Reconstructive Repair of Pectus Excavatum or Carinatum; Minimally Invasive Approach (Nuss Procedure), Wo

Thoracoscopy


Provider Portal

855-339-812721743 Reconstructive Repair of Pectus Excavatum or Carinatum; Minimally Invasive Approach (Nuss Procedure), w

Thoracoscopy


Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:22100 Resect Vertebra Part Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722101 Part Resec Vertebral Spinous Process Tho 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722102 Resect Vertebra Part Lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722103 Partial Excision of Posterior Vertebral Component for each additional 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722110 Exc Vertebra Part Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722112 Exc Vertebra Part Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722114 Exc Vertebra Part Lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722116 Partial Excision of Vertebral Body for each additional Vertebral Segment 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral

injection, inclusive of all imaging

guidance; cervicothoracic


Provider Portal

855-339-8127

22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral

injection, inclusive of all imaging

guidance; lumbosacral


Provider Portal

855-339-8127

22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral

injection, inclusive of all imaging guidance; each additional cerv


Provider Portal

855-339-812722513 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when

performed) using mechanical device (eg, kyphoplasty), 1 verteb


Provider Portal


performed) using mechanical device (eg, kyphoplasty), 1 verteb


Provider Portal


performed) using mechanical

device (eg, kyphoplasty), 1 verteb


Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:22532 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy To Prepare Interspace; Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722533 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy To Prepare Interspace; Lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722534 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy; Thoracic or Lumbar, Each Additional

Segment


Provider Portal

855-339-812722548 Arthrodes,Txs/Extraoral,Clivus-C1- 2 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722551 Arthrodesis, Anterior Interbody; Cervical Below C2 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression

of spinal cord and/or nerve roots; cervical below C2, each add


Provider Portal

855-339-812722554 Arthrodesis Ant Interbody-C2 Below 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722556 Arthrodesis Ant Interbody- Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722558 Arthrod,Interbdy Tech;lumbar, Allogf 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722590 Arthrodesis Post-Craniocervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722595 Arthrodesis,Poster.Tech,Atlas- Axis,C1-C2 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722600 Fusion Cervical Post < C1 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722610 Arthrodesis Post-Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722612 Arthrodesis,Posterior/ Posterolateral Tec 05-01-2018 Premera Blue Cross

Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:22614 Arthrodesis, each additional Vertebral Segment 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722630 Arthrodesis Post Interbody- Lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722632 Arthrodesis, each additional Interspace 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722633 Arthrodesis, Combined Post Or Postlatl Tech W Post Interbdy Tech,Incl Lamectmy &/Discectomy,Sgl Interspace &

Segmt; Lumb


Provider Portal

855-339-812722634 Arthrodesis, Combind Post Or Postlatl Tech W Post Interbdy Tech,Incl Lamectmy &/Discectomy,Sgl Interspce &

Segmt ;Ea Addl


Provider Portal

855-339-812722840 Pos.Instrumnt;e.g. Harringtn Rod 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722841 Internal Spinal Fixation by Wiring of Spinous Processes 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722842 Instrumentat Post W Segment Wiring 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722843 Posterior Segmental Instrumentation, 7 To 12 Vertebral Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722844 Posterior Segmental Instrumentation, 13 or More Vertebral Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722845 Anterior Instrumentation 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722846 Anterior Instrumentation, 4 To 7 Vertebral Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722847 Anterior Instrumentation, 8 or More Vertebral Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812722853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for

device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody

arthrodesis, each interspace (List separately in addition to code for primary procedure)


Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:22854 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation

for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection,

partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect. (List separately in

addition to code for primary procedure)


Provider Portal

855-339-8127

22856 Total Disc Arthroplasty, Anterior Approach, Including Discectomy with End Plate Preparation, Single Interspace,

Cervical


Provider Portal

855-339-812722859 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral

disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in



Provider Portal

855-339-8127

22861 Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace;

Cerv


Provider Portal

855-339-812722864 Removal of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace; Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812723470 Arthroplasty, glenohumeral joint, hemiarthroplasty 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812723472 Arthroplasty, total shoulder 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727130 Arthroplasty, acetabular, proximal femoral prosthetic replacement(total Hip arthroplasty), with or without autograft

or allograft


Provider Portal

855-339-812727132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance,

includes obtaining bone graft when performed, and placement of transfixing device


Provider Portal

855-339-812727280 Arthrodesis, Sacroiliac Joint 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727333 Exc Semilunar Cartilage Med + Lat 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727412 Autologous Chondrocyte Implantation, Knee 05-01-2018 Premera Blue Cross

Provider Portal

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Code: Description: Effective Date: Who to Contact for Review:27415 Rep Ligaments Knee+pes Anserin Tran 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) Advancement Pes

Anserinus


Provider Portal

855-339-812727446 Arthroplasty, knee, condyle and plateau, medial or lateral compartment 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727447 Arthroplasty, knee medical and lateral compartments with or without patella resurfacing(total knee arthroplasty) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727700 Arthroplasty Ankle 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727702 Arthroplasty, Ankle; with Implant (Total) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727703 Arthroplasty Ankle Second Reconstr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812727704 Removal of Ankle Implant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812728291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint;

with

implant


Provider Portal

855-339-8127

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

Provider Portal

855-339-812729862 Arthroscopy, Hip, Surg; W Chondroplsty, Arthroplsty, & Labrum Resectn 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812729863 Arthroscopy, Hip, Surgical; With Synovectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812729866 Arthroscopy, Knee, Surgical; Osteochondral Autograft(S) (Eg, Mosaicplasty) (Includes Harvesting Of The Autograft) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812729867 Arthroscopy, Knee, Surgical; Osteochondral Allograft (Eg, Mosaicplasty) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:29868 Arthroscopy, Knee, Surgical; Meniscal Transplantation (Includes Arthrotomy For Meniscal Insertion), Medial Or

Lateral


Provider Portal

855-339-812729879 Arthroscopy Knee 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812729886 Arthrosc,Knee,Surg;drill-Intact Ost.Diss 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730400 Rhinoplasty Primary Partial 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730410 Rhinoplasty, Prim; complete, Extern. Parts 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730420 Rhinoplasty Primary Maj Septal Rep 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730430 Rhinoplasty,2ndary; minor Revision 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730435 Rhinoplasty, 2ndary; intermediate revision (bony work with osteotomies) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730450 Rhinoplasty, 2ndary; major revision (nasal tip work and osteotomies) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730460 Rhinoplasty for nasal deformity 2ndary to congenital cleft lip and/or palate, incl columellar lengthening; tip only 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812730462 Rhinoplasty for nasal deformity 2ndary to congenital cleft lip and/or palate, incl columellar lengthening; tip, septum,

osteotomies


Provider Portal

855-339-812731295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g. balloon dilation), transnasal or via

canine fossa


Provider Portal

855-339-812731296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g. balloon dilation) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812731297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g. Balloon dilation) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g. balloon dilation) 08-16-2018 Premera Blue Cross

Provider Portal

855-339-812731643 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for

intracavitary radioelement application


AIM Provider Portal

866-666-077632664 Thoracoscopy, Surgical; with Thoracic Sympathectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812732850 Donor Pneumonectomy(ies) W Prep and Maintenance of Allograft (Cadaver) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812732851 Lung Transplant, Single; Without Cardiopulmonary Bypass 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812732852 Lung Transplant, Single, with Cardiopulmonary Bypass 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812732853 Lung Transplant, Double (Sequential or En Bloc); Without Cardpulm Bypass 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812732854 Lung Transplant, Double (Sequential or En Bloc); with CardPulm Bypass 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812732855 Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Unilateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812732856 Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Bilateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733282 Implantation of patient-activated cardiac event recorder 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy,

transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when

performed, and radiological supervision and interpretation


Provider Portal

855-339-812733930 Donr Cardiectmy- Pneum,Prep/Main.Hom 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733933 Backbench Standard Preparation Of Cadaver Donor Heart/Lung Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:33935 Heart-Lung Transplant W Recipient Cardi/ 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733940 Donor cardiectomy (including cold preservation) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733944 Backbench Standard Preparation Of Cadaver Donor Heart Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733945 Heart transplant, w/or without recipient cardiectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733975 Implantation of Ventricular Assist Device; Single Ventricle Support 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733976 Implantation of Ventricular Assist Device; Biventricular Support 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733979 Insertion Of Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733990 Insertion Of Ventricular Assist Device, Percutaneous; Arterial Access Only 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812733991 Insertion Of Ventricular Assist Device, Percutaneous; Both Arterial And Venous Access, With Transseptal Puncture 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812734841 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural

hematoma, or traumatic

disruption) by deployment of a fenestrate


Provider Portal

855-339-8127

34842 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural

hematoma, or traumatic disruption) by deployment of a

fenestrate


Provider Portal

855-339-812734843 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural


fenestrate; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])


Provider Portal

855-339-8127

34844 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural


fenestrate; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])


Provider Portal

855-339-8127

34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm,

pseudoaneurysm, dissection, penetrating ulcer, intramural

hematoma, or traumatic disruption


Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:34846 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,

penetrating ulcer, intramural hematoma, or traumatic disruption


Provider Portal

855-339-812734847 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,

penetrating ulcer, intramural hematoma, or traumatic disruption)


Provider Portal

855-339-812734848 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,

penetrating ulcer, intramural hematoma, or traumatic disruption)


Provider Portal

855-339-812736217 Select Cath Plcmt Art;3rd Ord Thrc 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812736218 Select Cath Plcmt Art; Add 2nd/3rd Order 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812736468 1+ Injec-Scler.Solutions,Spider Vein; Li 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812736470 Injection Sclerosing Solution Single Vein 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812736471 Inject Sclerosing Agent Mult Veins 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812736473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring,

percutaneous, mechanochemical; first vein treated


Provider Portal

855-339-812736474 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring,

percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access

sites (List separately in addition to code for primary procedure)


Provider Portal

855-339-8127

36475 Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Radiofrequency; First Vein Treated 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812736476 Endovenous Ablation Therapy Incompetent Vein, Extremity, Percut, Radiofreq; 2nd & Subsequent Veins,Same

Extrem,Sep Sites


Provider Portal

855-339-812736478 Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Laser; First Vein Treated 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812736479 Endovenous Ablation Therapy Incompetent Vein, Extremity, Percutaneous, Laser; 2nd & Subseq Veins, Same

Extrem, Sep Sites


Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:36516 Therapeutic Apheresis; with Extracorporeal Selective Adsorption or Selective Filtration and Plasma Reinfusion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737188 Percutaneous transluminal mechanical thrombectomy, vein(s), repeat treatment on subsequent day of thrombolytic

therapy


Provider Portal

855-339-812737700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737718 Ligation, division, and stripping, short saphenous vein 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737735 Ligation & Strip Saphen+ulcer Unil 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737760 Ligation Perforators Rad (Linton) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737761 Ligation of Perforator Vein(s), Subfascial, Open, Including Ultrasound Guidance, When Performed, 1 Leg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737765 Stab Phlebectomy of Varicose Veins, One Extremity; 10-20 Stab Incisions 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737766 Stab Phlebectomy of Varicose Veins, One Extremity; More Than 20 Incisions 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812737785 Ligation 2ndary Varicose Vein Unilateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738204 Management of Recipient Hematopoietic Progenitor Cell Donor Search and Cell Acquisition 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738205 Blood-Derived Hematopoietic Progenitor Cell Harvesting for Transplantation, Per Collection; Allogenic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:38206 Blood-Derived Hematopoietic Progenitor Cell Harvesting for Transplantation, Per Collection; Autologous 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738207 Transplant Preparation of Hematopoietic Progenitor Cells; Cryopreservation and Storage 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738208 Transplant Preparation of Hematopoietic Progenitor Cells; Thawing of Previously Frozen Harvest 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738209 Transplant Preparation of Hematopoietic Progenitor Cells; Washing of Harvest 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738210 Transplant Preparation of Hematopoietic Progenitor Cells; Specific Cell Depletion Within Harvest, T- Cell Depletion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738211 Transplant Preparation of Hematopoietic Progenitor Cells; Tumor Cell Depletion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738212 Transplant Preparation of Hematopoietic Progenitor Cells; Red Blood Cell Removal 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738213 Transplant Preparation of Hematopoietic Progenitor Cells; Platelet Depletion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738214 Transplant Preparation of Hematopoietic Progenitor Cells; Plasma (Volume) Depletion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738215 Transplant Preparation of Hematopoietic Progenitor Cells; Cell Concentration in Plasma, Mononuclear, or Buffy

Coat Layer


Provider Portal

855-339-812738230 Harvest Bone Marrow For Transplant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738232 Bone Marrow Harvesting For Transplantation; Autologous 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738240 Bone Marrow Transplantation; Allogenic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812738241 Bone Marrow Transplant; Autologous 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:38242 Bone Marrow or Blood-Derived Peripheral Stem Cell Transplantation; Allogeneic Donor Lymphocyte Infusions 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812741120 Glossectomy; less than one-half tongue 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812741500 Fixation of tongue, mechanical, other than suture (eg, K-wire) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742120 Resect Palateor Extensive Lesion 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742140 Uvulectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742145 Uvuloplatopharyngoplasty 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742160 Destruct Lesion Palate/Uvula 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742226 Lengthening of Palate, and Pharyngeal Floor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742227 Lengthen Palate W Island Flap 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742235 Repair Anterior Palate Including Vomer Flap 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742950 Pharyngoplasty 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812742953 Repair Pharyngoesophageal 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743229 Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s) or other lesion(s) 08-16-2018 Premera Blue Cross

Provider Portal

855-339-812743270 Esohpagogastroduodenoscopy flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) 08-16-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:43327 Esophagogastric Fundoplasty Partial Or Complete; Laparotomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743644 Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric Bypass And Roux-En-Y Gastroenterostomy (Roux Limb

<= 150 Cm)


Provider Portal

855-339-812743645 Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass And Small Intestine Reconstruction 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743647 Laparoscopy, Surgical; Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743648 Laparoscopy, Surgical; Revision or Removal of Gastric Neurostimulator Electrodes, Antrum 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743659 Unlisted laparoscopy procedure, stomach 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743770 Laparoscopy, surg, gastric restrictive procedure; placement of adjustable gastric band 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component

only


Provider Portal

855-339-812743774 Laparoscopy, surg, gastric restrictive procedure; removal of adjustable gastric band and

subcutaneous port components


Provider Portal

855-339-812743775 Laparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy (ie, Sleeve Gastrectomy) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743843 Gastroplsty Non Vert-Banded Obesity 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743845 Gastric Stapling Morbid Obesity 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:43846 Gastric Bypass W/Roux-En-Y- Morbid Obesity 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743847 Gstrc Restricve Prcd w Gstrc Byps F Morbid Obesty; w/Sml Bowel Rcnstn 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743848 Revision of Gastrc Restrictive Prcd For Morbid Obesity (Separate Prcd) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743850 Rev Gastroduodenostomy w/o Vagotomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743855 Rev Gastroduodenostomy w/ reconstruction; with vagotomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743860 Rev Gastrojejunostomy w/o Vagotomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743865 Gastrojejunostomy; with Vagotomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743881 Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum, Open 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812743882 Revision or Removal of Gastric Neurostimulator Electrodes, Antrum, Open 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812744133 Donor Enterectomy, Open, w Allograft Prep & Maintenance; Living Donor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812744136 Intestinal Allotransplantation; From Living Donor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747133 Donor Hepatectomy,W Prep & Maintenance-H 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747135 Transplant Liver (Recipient) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747140 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Left Lateral Segment Only 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:47141 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Left Lobectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747142 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Right Lobectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747143 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; Without Trisegment Or Lobe Split 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747144 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; W Trisegment Split Of Graft Into Two Partial

Grafts


Provider Portal

855-339-812747145 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; With Lobe Split Of Graft Into Two Partial

Grafts


Provider Portal

855-339-812747146 Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Venous

Anastomosis, Each


Provider Portal

855-339-812747147 Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Arterial

Anastomosis, Each


Provider Portal

855-339-812747370 Laparoscopy, Surgical, Ablation Of One Or More Liver Tumor(S); Radiofrequency 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747371 Laparoscopy, Surgical, Ablation Of One Or More Liver Tumor(S); Cryosurgical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747379 Unlisted Laparoscopic Procedure, Liver 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747380 Ablation, Open, Of One Or More Liver Tumor(S); Radiofrequency 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747381 Ablation, Open, Of One Or More Liver Tumor(S); Cryosurgical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747382 Ablation, One Or More Liver Tumor(S), Percutaneous, Radiofrequency 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812747383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:48550 Donor Pancreatectomy For Transplantation 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812748551 Backbench Standard Preparation Of Cadaver Donor Pancreas Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812748552 Backbench Reconstruction Of Cadaver Donor Pancreas Allograft Prior To Transplantation, Venous Anastomosis,

Each


Provider Portal

855-339-812748554 Transplantation of Pancreatic Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812748556 Removal of Transplanted Pancreatic Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750300 Nephrectomy Cadaver Donor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750320 Donor Nephrectomy from Living Donor,Unil 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750323 Backbench Standard Preparation Of Cadaver Donor Renal Allograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750325 Backbench Standard Preparation Of Living Donor Renal Allograft (Open Or Laparoscopic) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750327 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Venous

Anastomosis, Each


Provider Portal

855-339-812750328 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Arterial

Anastomosis, Each


Provider Portal

855-339-812750329 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Ureteral

Anastomosis, Each


Provider Portal

855-339-812750340 Nephrectomy Recipient Unilateral 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750360 Transplant Renal Homograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:50365 Renal Homotxplnt,Implnt Gft;w/Recipnt Ne 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750370 Removal of Transplanted Homograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750380 Transplant Renal Autograft 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812750547 Laparoscopy, surgical; donor nephrectomy from living donor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812752287 Cystourethroscopy, With Injection(s) For Chemodenervation Of The Bladder 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812753860 Transurethral Radiofrequency Micro- Remodeling Of The Female Bladder Neck And Proximal Urethra 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812755873 Cryosurgical Ablation of the Prostate (Incl Ultrasonic Probe Placemnt) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812755875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or

without cystoscopy


AIM Provider Portal

866-666-077655920 Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial

radioelement application


AIM Provider Portal

866-666-077657155 Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077657156 Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077658346 Insertion of Heyman capsules for clinical brachytherapy 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077661517 Implantation of Brain Intracavitary ChemoTherapy Agent 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812761650 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial,

including catheter placement,

diagnostic angiography, and imaging guidance; initial vascular territory


Provider Portal

855-339-8127































Code: Description: Effective Date: Who to Contact for Review:61651 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial,

including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (List

separately in addition to

code for primary procedure)


Provider Portal

855-339-8127

61850 Twst Drl/Brr Hole-Impl Elec;corticl 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812761860 Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812761863 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; First

Array


Provider Portal

855-339-812761864 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; ea addl

Array


Provider Portal

855-339-812761867 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; First

Array


Provider Portal

855-339-812761868 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; ea addl

Array


Provider Portal

855-339-812761880 Revis/Remv Intracr.Neurost.Electrod 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812762287 Asp Percutaneous Diskectomy One/Mult Lev 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812762290 Inj Proc Diskography Ea Level; Lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812762291 Inject For Diskography Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763001 Laminec-Expl/Decomp,1,2 Segm;cerv. 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763003 Decompress Spine <2 Seg Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763005 Laminec=expl/Decomp,1,2 Segm;lumb 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:63011 Laminec-Expl/Decomp,1,2 Segm;sacr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763012 Laminectomy/Rem Facets,Lumbar (Gill Type) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763015 Laminec-Expl/Dec,3+seg;cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763016 Decompress Spine >2 Seg Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763017 Laminec-Expl/Dec,3+seg; lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763020 Exc Iv Disk Cervical Unilat 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763030 Exc Iv Disk Lumbar Unilat 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763035 Exc Iv Disk Cervical/Lumb >1 Space 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763040 Laminotomy W Dec Nrv Rts;reex;cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763042 Laminotomy W Dec Nrv Rts;reex;lumb 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763043 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Cerv Interspace 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763044 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Lumb Interspace 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763045 Laminectomy W Facetectomy- Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763046 Laminect, 1 Segm; thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:63047 Laminectomy W Facetectomy- Lumbar 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763048 Lam.,Facetect,Foraminot;ea Adtl.Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763050 Laminoplasty, Cervical, With Decompression Of The Spinal Cord, Two Or More Vertebral Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763051 Laminoplasty, Cerv, W Decompression Of Spinal Cord, 2 Or > Verteb Segments; W Reconstruction Of Posterior Bony

Elements


Provider Portal

855-339-812763055 Decompress Spine Transpedic- Thorac 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763056 Transped App/Decomp;sgle;lumb 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763057 Decomp Spine Transpedic-Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763064 Decompress Spine Costoverteb 1 Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763066 Decomp Spine Costoverteb-Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763075 Diskectomy,Ante.W/Decomp Cord/Root; cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763076 Exc Iv Disk Ant Cervical >1 Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763077 Diskectomy,Ante.W/Decomp Cord/Root; thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763078 Exc Iv Disk Ant Thoracic-Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763081 Vert Corpectomy, Part/Comp.; anter. approach w/ decompression; cervical, single segment 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:63082 Vert Corpectomy, Part/Comp.; anter. approach w/ decompression; cerv, each additional segment 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763085 Vert Corpect., Part/Comp, Transthoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763086 Corpecto Verteb Thoracic Ea Add Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763087 Vert.Corpect;thoracolumbar/Tho r/Lumbar;s 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763090 Vert.Corpec;peritoneal Appr.;single 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763101 Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression of Spinal Cord/Nerve Roots; Thoracic, Sgl

Segment


Provider Portal

855-339-812763103 Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression Spinal Cord/Nerve Rts; Thoracic/Lumbar,

ea addl Seg


Provider Portal

855-339-812763170 Laminectomy W Myelotomy;cerv,Thoracic,Th 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763180 Section Dentate Lig Cervical <2 Seg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763182 Laminec/Section Ligaments W/Wo Grft,Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763185 Rhizotomy <2 Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763190 Rhizotomy >2 Segments 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763191 Section Spinal Accessory Nerve Unil 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763194 Cordotomy Unilat 1 Stage Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127




























Code: Description: Effective Date: Who to Contact for Review:63195 Cordotomy Unilat 1 Stage Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763196 Cordotomy Bilat 1 Stage Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763197 Laminect W Cordotomy;both Tracts;1 Stg;t 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763198 Cordotomy Bilat 2 Stage Cervical 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763199 Laminect.W Cordotmy;both Tracts;2 Stg;th 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763200 Relase Tethered Spinal Cord 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763265 Laminect;intraspinal Lesion;cerv. 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763266 Exc Les Intraspin Extradur- Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763267 Laminect;intraspinal Lesion;lumb 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763270 Lamin-Exc Intrasp.Les,Intradur;cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763271 Exc Les Intraspin Intradur- Thoracic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763272 Lamin-Exc Intrasp.Les,Intradur;lumb 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763275 Lam,Bx/Exc Intrasp.Neo;extradur,Cer 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763276 Exc Intraspin Neopl Extradur- Thorac 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127




























Code: Description: Effective Date: Who to Contact for Review:63280 Lam,Bx/Exc Int.Neo;intra,Extra,Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763281 Exc Intraspin Neopl Extramed- Thorac 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763285 Lam,Bx/Exc In.Neo;intradur,Im,Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763286 Exc Intraspin Neopl Intramed- Thorac 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763287 Lam,Bx/Exc Neo;intradur,Im,Thoracol 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763295 Osteoplastic Reconstruction Of Dorsal Spinal Elements, Following Primary Intraspinal Procedure (List separately in



Provider Portal

855-339-812763300 Vert.Corpectmy,1 Seg;extradurl,Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763301 Corpectomy Verteb-Thorac Transthor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763302 Vert.Corpectm,1;extra,Thor- Thoracol 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763304 Vert.Corpectmy,1 Seg;intradurl,Cerv 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763305 Corpectomy Verteb-Thorac Transthor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763306 Vert.Corp,1;intradur,Thor- Thoracol 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763307 Vert.Corpec,ExcLes,1;intradur,Lumb/ Sac- 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812763308 Vertebral Corpectomy; ea. Add. Segment 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:63650 Percutaneous implantation of neurostimulator electrode array, epidural 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077663655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077663663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s),

including fluoroscopy, when performed


AIM Provider Portal

866-666-077663664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via

laminotomy or laminectomy, including fluoroscopy, when performed


AIM Provider Portal

866-666-077663685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077663688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077664479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT);

cervical or thoracic, single level


AIM Provider Portal


cervical or thoracic, each additional

level (List separately in addition to code for primary procedure)


AIM Provider Portal

866-666-0776

64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT);

lumbar or sacral, single level


AIM Provider Portal


lumbar or sacral, each additional level (List separately in addition to code for primary procedure)


AIM Provider Portal

866-666-077664553 Percutaneous implantation of neurostimulator electrode array; cranial nerve 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764561 Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including

image guidance, if performed


Provider Portal

855-339-812764568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to

existing pulse generator


Provider Portal

855-339-8127





































Code: Description: Effective Date: Who to Contact for Review:64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764581 Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764590 Insertion/replacement of periph or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764595 Revision/removal of periph or gastric neurostimulator pulse generator or receiver 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764612 Dest Neurolytic Agent; Muscle Enervated 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical

dystonia, spasmodic torticollis)


Provider Portal

855-339-812764617 Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance

by needle

electromyography, when performed


Provider Portal

855-339-812764633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT);

cervical or thoracic, single facet joint


AIM Provider Portal


cervical or thoracic, each additional

facet joint (List separately in addition to code for primary procedure)


AIM Provider Portal

866-666-0776

64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT);

lumbar or sacral, single facet joint


AIM Provider Portal


lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)


AIM Provider Portal

866-666-077664642 Chemodenervation of one extremity; 1-4 muscle(s) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764643 Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code

for primary procedure)


Provider Portal

855-339-812764644 Chemodenervation of one extremity; 5 or more muscle(s) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127




























Code: Description: Effective Date: Who to Contact for Review:64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to

code for primary procedure)


Provider Portal

855-339-812764646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764647 Chemodenervation of trunk muscle(s); 6 or more muscle(s) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764650 Chemodenervation of eccrine glands; both axillae 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812764653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812767218 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation

of source (includes removal of source)


AIM Provider Portal

866-666-077667900 Repair Brow Ptosis (Supraciliary/Mid/Cor) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812767901 Repair Blepharoptosis; Frontalis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812767902 Rep Blepharoptosis Frontalis+sling 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812767903 Rep. Bleph;adv.;internal Appr. 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812767904 Rep Blepharoptosis Levator External 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812767906 Rep.Bleph;sup.Rectus Tech,Fasc.Slng 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812767908 Rep.Bleph;conjunct-Tarso- Lev.Resec 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812769714 Implantation, osseointetrated implant, temporal bone, with percutaneous attachment to external speech

processor/cochlear stimulator; without mastoidectomy


Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:69930 Cochlear Device Implantation, W/Wo Masto 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812770336 MRI of the Temporomandibular Joint(s) 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670450 CT of head, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670460 CT of head, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670470 CT of head, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670480 CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670481 CT of orbit, sella or posterior fossa and outer, middle or inner ear, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670482 CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast, followed by re-imaging with

contrast


AIM Provider Portal

866-666-077670486 CT of maxillofacial area, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670487 CT of maxillofacial area, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670488 CT of maxillofacial area, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670490 CT, soft tissue neck, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670491 CT, soft tissue neck, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670492 CT, soft tissue neck, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed,

and image post processing


AIM Provider Portal

866-666-077670498 CTA, neck, with contrast material(s), including noncontrast images, if performed, and image post-

processing


AIM Provider Portal

866-666-077670540 MRI orbit, face and neck, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670542 MRI orbit, face and neck, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670543 MRI orbit, face and neck, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670544 Magnetic resonance angiography, head, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670545 Magnetic resonance angiography, head, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670546 Magnetic resonance angiography, head, without contrast, followed by re- imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670547 MRA, neck, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670548 MRA, neck, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670549 MRA, neck, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670551 MRI Head, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670552 MRI Head, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077670553 MRI Head, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body

part movement and/or visual stimulation, requiring physician or psychologist administration of entire

neurofunctional testing


AIM Provider Portal

866-666-077670555 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body

part movement and/or visual stimulation, requiring physician or psychologist administration of entire

neurofunctional testing


AIM Provider Portal

866-666-077671250 Chest CT without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077671260 Chest CT with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077671270 Chest CT without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077671275 CTA of chest (non-coronary), with contrast material(s), including non-

contrast images, if performed, and image post-processing


AIM Provider Portal

866-666-077671550 MRI chest, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077671551 MRI chest, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077671552 MRI chest, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077671555 MRA of chest (excluding the myocardium) without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672125 CT of cervical spine, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672126 CT of cervical spine, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672127 CT of cervical spine, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672128 CT of thoracic spine, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:72129 CT of thoracic spine, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672130 CT of thoracic spine, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672131 CT of lumbar spine, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672132 CT of lumbar spine, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672133 CT of lumbar spine, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672141 MRI of cervical spine, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672142 MRI of cervical spine, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672146 MRI of thoracic spine, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672147 MRI of thoracic spine, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672148 MRI of lumbar spine, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672149 MRI of lumbar spine, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672156 MRI of cervical spine, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672157 MRI of thoracic spine, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672158 MRI of lumbar spine, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:72159 Magnetic resonance angiography of spinal canal 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672191 Computed tomographic angiography, pelvis, with contrast material(s), including non-contrast images, if performed,

and image post- processing


AIM Provider Portal

866-666-077672192 CT of pelvis, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672193 CT of pelvis, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672194 CT of pelvis without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672195 MRI of pelvis, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672196 MRI of pelvis, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672197 MRI of pelvis, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672198 Magnetic resonance angiography, pelvis; without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077672285 Diskography Cervical Rad S&I 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812772295 Diskography Lumbar Rad S&I 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812773200 CT upper extremity, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673201 CT upper extremity, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673202 CT upper extremity, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776








































Code: Description: Effective Date: Who to Contact for Review:73206 Computed tomographic angiography, upper extremity, with contrast material(s), including non-contrast images, if

performed, and image post-

processing


AIM Provider Portal

866-666-077673218 MRI upper extremity, non-joint, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673219 MRI upper extremity, non-joint, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673220 MRI upper extremity, non-joint, without contrast, followed by re- imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673221 MRI upper extremity, any joint, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673222 MRI upper extremity, any joint, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673223 MRI upper extremity, any joint, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673225 Magnetic resonance angiography, upper extremity, without and with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673700 CT lower extremity without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673701 CT lower extremity with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673702 CT lower extremity without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673706 Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if

performed, and image post-processing


AIM Provider Portal

866-666-077673718 MRI lower extremity, other than joint, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673719 MRI lower extremity, other than joint, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:73720 MRI lower extremity, other than joint, without contrast followed by re- imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673721 MRI lower extremity, any joint, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673722 MRI lower extremity, any joint, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673723 MRI lower extremity, any joint, without contrast followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077673725 Magnetic resonance angiography, lower extremity, without and with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674150 CT abdomen; without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674160 CT abdomen; with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674170 CT abdomen; without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images,

if performed, and image

postprocessing


AIM Provider Portal

866-666-0776

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

performed, and image post-

processing


AIM Provider Portal

866-666-0776

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

AIM Provider Portal

866-666-077674177 CT of abdomen and pelvis, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674178 CT of abdomen and pelvis, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674181 MRI of abdomen, without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:74182 MRI of abdomen, with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674183 MRI of abdomen, without contrast, followed by re-imaging with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674185 Magnetic resonance angiography, abdomen; without or with contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674261 Diagnostic CT colonography without contrast 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674262 Diagnostic CT colonography with contrast including non-contrast images if performed 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674263 Screening CT colonography including image post-processing 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077674712 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed;

single or first gestation


AIM Provider Portal

866-666-077674713 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed

;each additional gestation (List separately in addition to code for primary procedure)


AIM Provider Portal

866-666-077675557 Cardiac MRI for morphology and function, without contrast material 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077675559 Cardiac MRI for morphology and function, without contrast material, with stress imaging 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077675561 Cardiac MRI for morphology and function, without contrast material, followed by contrast material 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077675563 Cardiac MRI for morphology and function, without contrast material, followed by contrast material with stress

imaging


AIM Provider Portal

866-666-077675565 Add-on code to be used in conjunction with 75557, 75559, 75561, and 75563. As such, this code does not require

separate review.


AIM Provider Portal

866-666-077675571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery calcium 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including

3-D image post-processing, assessment of cardiac function, and evaluation of venous structures if performed)


AIM Provider Portal

866-666-077675573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the

setting of congenital heart disease (including 3-D post-processing, assessment of left ventricular cardiac function,

right ventricular structure and function and evaluation of venous structures, if performed)


AIM Provider Portal

866-666-0776

75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (where present), with contrast

material, including 3-D image post- processing (including evaluation of cardiac structure and morphology,

assessment of cardiac function, and evaluation of venous structures, if performed)


AIM Provider Portal

866-666-0776

75635 Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with

contrast material(s), including noncontrast images, if performed, and image post-processing


AIM Provider Portal

866-666-077675665 Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812775685 Angiography Vertebral Cervical Intracran 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812776376 3D rendering w/ interpretationand reporting of CT MRI, US or other Tomographyic modality with image

postprocessing under concurrent supervision


Provider Portal

855-339-812776380 CT, limited or localized follow-up study 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812776390 Magnetic Resonance Spectroscopy (MRS) 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677014 CT guidance for placement of radiation therapy fields 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677058 MRI of breast, without and/or with contrast material(s); unilateral 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677059 MRI of breast, without and/or with contrast material(s); bilateral 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677084 MRI of bone marrow blood supply 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776





































Code: Description: Effective Date: Who to Contact for Review:77295 3-dimensional radiotherapy plan, including dose-volume histograms 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677301 Intensity modulated radiation therapy plan, including dose volume histogram for target and critical structure partial

tolerance specifications (IMRT treatment plan)


AIM Provider Portal

866-666-077677316 Brachytherapy isodose plan; simple (1-4 sources or 1 channel), includes basic dosimetry calculations (Do not bill

77300)


AIM Provider Portal

866-666-077677317 Brachytherapy isodose plan; intermediate (5-10 sources or 2-12 channels), includes basic dosimetry calculation (Do

not bill 77300)


AIM Provider Portal

866-666-077677318 Brachytherapy isodose plan; complex (over 10 sources or over 12 channels), includes basic dosimetry calculations

(Do not bill 77300)


AIM Provider Portal

866-666-077677338 Multi-leaf collimator (MLC) devise(s) for intensity modulated radiation therapy (IMRT), design and construction per

IMRT plan


AIM Provider Portal

866-666-077677370 Special medical radiation physics consultation 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677371 Radiation treatment delivery, stereotactic radiosurgery (SRS) complete course of treatment of cranial lesion(s)

consisting of 1 session; multi-source Cobalt 60 based


AIM Provider Portal

866-666-077677372 Radiation treatment delivery, stereotactic radiosurgery (SRS) complete course of treatment of cranial lesion(s)

consisting of 1 session; linear accelerator based


AIM Provider Portal

866-666-077677373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance,

entire course not to exceed 5 fractions


AIM Provider Portal

866-666-077677385 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; simple 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; complex 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677387 Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction

tracking, when performed


AIM Provider Portal

866-666-077677402 Radiation treatment delivery, up to 5 MeV; simple. All of the following criteria are met (and none of the complex or

intermediate criteria are met):single treatment area, one or two ports and two or fewer simple blocks


AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:77407 Radiation treatment delivery, up to 5 MeV; intermediate. Any of the following criteria are met (and none of the

complex criteria are met): 2 separate treatment areas, 3 or more ports on a single treatment area, or 3 or more

simple blocks


AIM Provider Portal

866-666-077677412 Radiation treatment delivery, up to 5 MeV; complex. Any of the following criteria are met: 3 or more separate

treatment areas, custom blocking, tangential ports, wedges, rotational beam, field-in-field or other tissue

compensation that does not meet IMRT guidelines, or electron beam.


AIM Provider Portal

866-666-0776

77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1

session)


AIM Provider Portal

866-666-077677435 Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including

image guidance, entire course not to exceed 5 fractions


AIM Provider Portal

866-666-077677470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral or endocavitary irradiation) 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677520 Proton beam delivery to a sgl treatment area, sgl port, custom block 05-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677522 Proton Treatment Delivery; Simple, with Compensation 05-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677523 Proton beam delivery to one or two treatment areas, two or more ports, two or more custom blocks 05-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677525 Proton Treatment Delivery; Complex 05-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077677761 Intracavitary radiation source application; simple 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677762 Intracavitary radiation source application; intermediate 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677763 Intracavitary radiation source application; complex 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077677767 Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when

performed; lesion diameter up to 2.0 cm or 1 channel


Provider Portal

855-339-812777768 Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when

performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions


Provider Portal

855-339-8127








































Code: Description: Effective Date: Who to Contact for Review:77770 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic

dosimetry, when performed; 1 channel


Provider Portal

855-339-812777771 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic

dosimetry, when performed; 2-12 channels


Provider Portal

855-339-812777772 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic

dosimetry, when performed; over 12 channels


Provider Portal

855-339-812777778 Interstitial radiation source application; complex, includes supervision, handling, loading of radiation source, when

performed


AIM Provider Portal

866-666-077678451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative

wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single

study, at rest or stress (exercise or pharmacologic)


AIM Provider Portal

866-666-0776

78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative

wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single

study, at rest or stress)


AIM Provider Portal

866-666-0776

78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first

pass or gated technique, additional quantification, when performed);

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


AIM Provider Portal

866-666-077678454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first

pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress

(exercise or pharmacologic) and/or redistribution and/or rest reinjection


AIM Provider Portal

866-666-0776

78459 PET myocardial, metabolic evaluation 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678466 Planar, infarct avid; qualitative or quantitative 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678468 Planar, infarct avid; with ejection fraction by first pass technique 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678469 SPECT, infarct avid; with or without quantification 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678472 Gated equilibrium; planar, single study, wall motion plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678473 Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776





































Code: Description: Effective Date: Who to Contact for Review:78481 First pass technique; single study, wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678483 First pass technique; multiple studies, wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678491 PET myocardial perfusion, single study 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678492 PET myocardial perfusion, multiple studies 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678494 Gated equilibrium: SPECT, at rest, wall motion study plus ejection fraction 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678496 This code is an add-on code to be used in conjunction with 78472. As such, this code does not require separate

review.


AIM Provider Portal

866-666-077678608 PET brain, metabolic evaluation 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678609 PET brain, perfusion evaluation 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678811 PET imaging, limited area 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678812 PET imaging, skull to mid-thigh 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678813 PET imaging, whole body 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678814 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077678815 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid-

thigh


AIM Provider Portal

866-666-077678816 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776











































Code: Description: Effective Date: Who to Contact for Review:81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence

analysis and full duplication/deletion analysis


Provider Portal

855-339-812781200 Aspa (Aspartoacylase) (Eg, Canavan Disease) Gene Analysis, Common Variants (Eg, E285A, Y231X) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781201 APC (Adenomatous Polyposis Coli) Gene Analysis; Full Gene Sequence 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781202 APC (Adenomatous Polyposis Coli) Gene Analysis; Known Familial Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781203 APC (Adenomatous Polyposis Coli) Gene Analysis; Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781205 Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1, Beta Polypeptide) Gene Analysis, Common Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781210 Braf (V-Raf Murine Sarcoma Viral Oncogene Homolog B1) (Eg, Colon Cancer), Gene Analysis, V600E Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781211 Brca1, Brca2 Gene Analysis; Full Sequence Analysis And Common Duplication/Deletion Variants In Brca1 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781212 Brca1, Brca2 Gene Analysis; 185Delag, 5385Insc, 6174Delt Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781214 Brca1 Gene Analysis; Full Sequence Analysis And Common Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781215 Brca1 (Breast Cancer 1) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781216 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781217 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781225 Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 19), Gene Analysis, Common Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127





































Code: Description: Effective Date: Who to Contact for Review:81226 Cyp2D6 (Cytochrome P450, Family 2, Subfamily D, Polypeptide 6), Gene Analysis, Common Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

81227 Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 9), Gene Analysis, Common Variants (Eg, -2, -3, -5, -6) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781228 Cytogenomic Constitutional (Genome- Wide) Microarray Analysis; Interrogation Of Genomic Regions For Copy

Number Variants


Provider Portal

855-339-812781229 Cytogenomic Constitutional Microarray Analysis;Interrog Genomic Regns For Copy Numbr & Sgl Nuctide

Polymorphism Variants


Provider Portal

855-339-812781235 EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon

19 LREA deletion, L858R, T790M, G719A, G719S, L861Q)


Provider Portal

855-339-812781240 F2 (Prothrombin, Coagulation Factor Ii) (Eg, Hereditary Hypercoagulability) Gene Analysis, 20210G>A Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781241 F5 (Coagulation Factor V) (Eg, Hereditary Hypercoagulability) Gene Analysis, Leiden Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781243 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis; Evaluation To Detect Abnormal (Eg, Expanded) Alleles 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781244 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis; Characterization Of Alleles 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781250 G6Pc (Glucose-6-Phosphatase, Catalytic Subunit) Gene Analysis, Common Variants (Eg, R83C, Q347X) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781255 Hexa (Hexosaminidase A [Alpha Polypeptide]) Gene Analysis, Common Variants (Eg, 1278Instatc, 1421+1G>C,

G269S)


Provider Portal

855-339-812781256 Hfe (Hemochromatosis) (Eg, Hereditary Hemochromatosis) Gene Analysis, Common Variants (Eg, C282Y, H63D) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781260 Inhibtr Of Kappa Light Plypeptide Gene Enhancr In B-Cells, Kinase Complex-Assoc Protein Gene Analysis, Common

Variants


Provider Portal

855-339-812781275 Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg, Carcinoma) Gene Analysis, Variants In Codons 12 And 13 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127











































Code: Description: Effective Date: Who to Contact for Review:81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon

61, codon 146)


Provider Portal

855-339-812781280 Long Qt Syndrome Gene Analyses; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781281 Long Qt Syndrome Gene Analyses; Known Familial Sequence Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781282 Long Qt Syndrome Gene Analyses; Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781287 MGMT, methylation analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781288 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch

syndrome) gene analysis; promoter methylation analysis


Provider Portal

855-339-812781290 Mcoln1 (Mucolipin 1) (Eg, Mucolipidosis, Type Iv) Gene Analysis, Common Variants (Eg, Ivs3- 2A>G, Del6.4Kb) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781291 Mthfr (5,10- Methylenetetrahydrofolate Reductase) (Eg, Hereditary Hypercoagulability) Gene Analysis, Common

Variants


Provider Portal

855-339-812781292 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781293 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Known Familial Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781294 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781295 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781296 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Known Familial Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781297 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127





































Code: Description: Effective Date: Who to Contact for Review:81298 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781299 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Known Familial Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781300 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781302 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781303 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Known Familial Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781304 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781311 NRAS (neuroblastoma RAS viral [v ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in

exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61)


Provider Portal

855-339-812781313 PCA3/KLK3 (prostate cancer antigen 3 {non-protein coding}/ kallikrein- related peptidase 3

{prostate specific antigen} ratio (eg prostate cancer)


Provider Portal

855-339-812781315 Promyelocytic Leukemia/Retinoic Acid Receptor Alpha, (T(15;17)), Translocation Analysis; Common Breakpoints,

Qual/Quant


Provider Portal

855-339-812781316 Promyelocytic Leukemia/Retinoic Acid Receptor Alpha, (T(15;17)), Translocation Analysis; Single Breakpoint,

Qual/Quant


Provider Portal

855-339-812781317 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781318 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Known Familial Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781319 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Duplication/Deletion Variants 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781321 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127











































Code: Description: Effective Date: Who to Contact for Review:81322 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Known Familial Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781323 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Duplication/Deletion Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781324 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Duplication/Deletion Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781325 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Full Sequence Analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781326 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Known Familial Variant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781327 SEPT9 (Septin9) (eg, colorectal cancer) methylation analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781330 Smpd1(Sphingomyelin Phosphodiesterase 1, Acid Lysosomal) (Eg, Niemann-Pick Disease, Type A) Gene Analysis,

Common Variants


Provider Portal

855-339-812781331 Snrpn/Ube3A (Small Nuclear Ribonucleoprotein Polypeptide N And Ubiquitin Protein Ligase E3A), Methylation

Analysis


Provider Portal

855-339-812781332 Serpina1 (Serpin Peptidase Inhibitor, Clade A, Alpha-1 Antiproteinase, Antitrypsin, Member 1), Gene

Analysis,Common Variants


Provider Portal

855-339-812781350 Ugt1A1 (Udp Glucuronosyltransferase 1 Family, Polypeptide A1) (Eg, Irinotecan Metabolism), Gene

Analysis,Common Variants


Provider Portal

855-339-812781355 Vkorc1 (Vitamin K Epoxide Reductase Complex, Subunit 1) (Eg, Warfarin Metabolism), Gene Analysis, Common

Variants


Provider Portal

855-339-812781382 HLA class II typing, high resolutionn (ie, alleles or allele groups); one locus (eg, HLA- DRB1, - DRB3/4/5, -DQB1,

-DQA1, -DPB1, or -DPA1), each


Provider Portal

855-339-812781400 Molecular Pathology Procedure Level 1 05-01-2018 Premera Blue Cross

Provider Portal


Provider Portal

855-339-8127





































Code: Description: Effective Date: Who to Contact for Review:81402 Molecular Pathology Procedure Level 3 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781403 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or

duplication/deletion variants of 11-25 exons


Provider Portal


Provider Portal


Provider Portal


Provider Portal


Provider Portal


Provider Portal

855-339-812781412 Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial

dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel,

must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and

SMPD1


Provider Portal

855-339-8127

81413 Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic

polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2

genes, including KCNH2 and KCNQ1


Provider Portal

855-339-8127

81414 Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic

polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2

genes, including KCNH2 and KCNQ1


Provider Portal

855-339-8127

81415 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781416 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator

exome (eg, parents, siblings) (List separately in addition to code for primary procedure)


Provider Portal

855-339-812781417 Exome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained

exome sequence (eg, updated knowledge or unrelated condition/symptom)


Provider Portal

855-339-812781420 Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free

fetal DNA in maternal blood, must include analysis of chromosome


Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:81422 Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome),

circulating cell-free fetal DNA in maternal blood


Provider Portal

855-339-812781432 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary

endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 14 genes, including

ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53


Provider Portal

855-339-812781433 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary

endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2,

and STK11


Provider Portal

855-339-8127

81435 Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); genomic sequence

analysis panel, must include analysis of at least 7 genes


Provider Portal

855-339-812781436 Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); genomic sequence

analysis panel, must include duplication/deletion gene analysis panel, must include analysis of at least 8 genes


Provider Portal

855-339-812781437 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant

pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6

genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL


Provider Portal

855-339-8127

81438 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant

pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analysis

for SDHB, SDHC, SDHD, and VHL


Provider Portal

855-339-8127

81439 Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right

ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes,

including DSG2, MYBPC3, MYH7, PKP2, and TTN


Provider Portal

855-339-8127

81442 Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio- cutaneous syndrome, Costello syndrome,

LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least

12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1


Provider Portal

855-339-8127

81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic

algorithm reported as a disease activity score


Provider Portal

855-339-812781507 Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma,

algorithm reported as a risk score for each trisomy


Provider Portal

855-339-812781508 Fetal congenital abnormalities, biochemical assays of 2 proteins 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781509 Fetal congenital abnormalities, biochemical assays of 3 proteins 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781510 Fetal congenital abnormalities, biochemical assays of three analytes 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:81511 Fetal congenital abnormalities, biochemical assays of 4 analytes 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781512 Fetal congenital abnormalities, biochemical assays of 4 analytes 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812781525 Oncology (colon), mRNA, gene expression profiling by real-time RT- PCR of 12 genes (7 content and 5

housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as a recurrence score


Provider Portal

855-339-812781538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and

predictive algorithm reported as good versus poor overall survival


Provider Portal

855-339-812781540 Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content

and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-

embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype


Provider Portal

855-339-8127

81545 Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a

categorical result (eg, benign or suspicious)


Provider Portal

855-339-812781595 Cardiology (heart transplant), mRNA, gene expression profiling by real- time quantitative PCR of 20 genes (11

content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score


Provider Portal

855-339-812782106 Alpha-fetoprotein; amniotic fluid 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812783020 Hemoglobulin fractionation and quantitation, electrophoresis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812783021 Hemoglobin fractionation and quantitation, chromatography 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812786001 Allergen Specific Igg Quantitative or Semiquantitative, Each Allergen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812786003 Allergen Specific IGE each Panel 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812786005 Allergen Specific IGE Multiallergen Screen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812786813 Tissue Typing,Hla Typing, A,B,&/Or C,Mul 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:86816 Hla Typing Dr/Dq Single Antigen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812786817 Hla Typing Dr/Dq Multiple Antigens 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812786821 Hla Typing Lymphocyte Culture Mixed 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812786822 Hla Typing Lymphocyte Culture Prime 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788235 Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788240 Cryopreservation, freezing and storage of cells, each cell line 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788241 Thawing and expansion of frozen cells each aliquot 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788245 Chrom. An-Break.Syn;25cls, Ct 5,1kary 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788248 Chrom. An- Brk.Syn;100cls, Ct.20,2kary 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788249 Chromosome analysis for breakage syndromes score 100 cells clastogen stress 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788261 Chrom. Analy; Ct.5 Cells, 1 Kary, Band 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788263 Chrom.Anal;ct.45 Clls-Mosaic, 2 Kary, Bands 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788269 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6/12 colonies, 1 karyotype, with banding 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:88271 Molecular cytogenetics DNA probe each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788273 Molecular cypogenetics; chromosomal in situ hybridization, analyze 10-30 cells (eg for microdeletions) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788275 Molecular cytogenetics interphase in situ hybridization analyze 100-300 cells 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788280 Chromosomal analysis; additional karyotypes, each study 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812788291 Cytogenetics and molecular cytogenetics interpretation and report 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812790785 Interactive Diagnostic Interview (interactive complexity add-on code) Optum Behavioral Health


844-884-185590791 Psychiatric diagnostic evaluation (no medical services) Optum Behavioral Health


844-884-185590792 Psychiatric diagnostic evaluation with medical services Optum Behavioral Health


844-884-185590832 Psychotherapy, 30 min Optum Behavioral Health


844-884-185590833 30-minute psychotherapy Optum Behavioral Health




844-884-185590836 45-minute psychotherapy add-on code Optum Behavioral Health




844-884-185590838 Interactive individual therapy in IP, PHP, RTC care setting (60 min with med evaluation & mgmt) Optum Behavioral Health


844-884-1855





































Code: Description: Effective Date: Who to Contact for Review:90839 Psychotherapy for crisis, first 60 min Optum Behavioral Health


844-884-185590840 Crisis code add on for each additional 30 min Optum Behavioral Health


844-884-185590845 Psychoanalysis Optum Behavioral Health


844-884-185590846 Family psychotherapy without patient present Optum Behavioral Health


844-884-185590847 Family psychotherapy with patient present Optum Behavioral Health


844-884-185590849 Multiple family group psychotherapy Optum Behavioral Health


844-884-185590853 Group psychotherapy Optum Behavioral Health


844-884-185590865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes (replaces 90835) Optum Behavioral Health


844-884-185590867 Therapeutic repetitive transcranial magnetic stimulation treatment; planning Optum Behavioral Health


844-884-185590868 Therapeutic repetitive transcranial magnetic stimulation treatment; delivery and management Optum Behavioral Health


844-884-185590869 Therapeutic repetitive transcranial magnetic stimulation treatment; subsequent motor threshold redetermination

with delivery and management

Optum Behavioral Health


844-884-185590870 Outpatient ECT (single seizure) Optum Behavioral Health


844-884-185590871 Outpatient ECT (multiple seizure) Optum Behavioral Health


844-884-1855

90875 Individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy (20-

30 min)



844-884-1855











































Code: Description: Effective Date: Who to Contact for Review:90876 Individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy (45-

50 min)



844-884-1855

90880 Hypnotherapy Optum Behavioral Health


844-884-185590882 Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies,

employers, or institutions



844-884-185590885 Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other

accumulated data for medical diagnostic purposes



844-884-185590887 Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other

accumulated data to family or other responsible person, or advising them how to assist patient



844-884-185590889 Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or

consultative purposes) for other physicians, agencies, or insurance carriers



844-884-185590899 Unlisted psychiatric service or procedure Optum Behavioral Health


844-884-185590901 Biofeedback training by any modality Optum Behavioral Health


844-884-185590911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry Optum Behavioral Health


844-884-185591065 Breath hydrogen or methane test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth,

or oro- cecal gastrointestinal transit)


Provider Portal

855-339-812791110 Gastrointestinal Tract Imaging, Intraluminal (Eg, Capsule Endoscopy), Esophagus Through Ileum, w Phys Interp and

Report


Provider Portal

855-339-812791111 Gastrointestinal Tract Imaging, Intraluminal (Eg, Capsule Endoscopy), Esophagus with Physician Interpretation and

Report


Provider Portal

855-339-812791112 Gastrointestinal Transit And Pressure Measurement, Stomach Through Colon, Wireless Capsule, w/Interpretation

And Report


Provider Portal

855-339-812792597 Evaluation for use of Voice Prosthetic 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127


































Code: Description: Effective Date: Who to Contact for Review:93228 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to 30 Days; Physician Review

w/Report


Provider Portal

855-339-8127

93229 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to 30 Days; Technical Support 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812793303 Transthoracic echocardiography or congenital cardiac anomalies; complete 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693304 Transthoracic echocardiography or congenital cardiac anomalies; follow- up or limited study 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693306 Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when

performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography


AIM Provider Portal

866-666-077693307 Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler

echocardiography


AIM Provider Portal

866-666-077693308 Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler

echocardiography follow-up or limited study


AIM Provider Portal

866-666-077693312 TEE real-time with image documentation (2-D) (with or without M-mode recording) 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693313 Placement of transesophageal probe only 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693314 Image acquisition, interpretation and report only 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693315 TEE for congenital cardiac anomalies 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693316 Placement of transesophageal probe only (congenital cardiac anomalies) 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693317 Image acquisition, interpretation and report only (congenital cardiac anomalies) 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-077693320 This code is an add-on code to be used in conjunction with 93303, 93304, 93312, 93314, 93315, 93317, 93350,

93351. As such, this code does not require separate review


AIM Provider Portal

866-666-0776








































Code: Description: Effective Date: Who to Contact for Review:93321 This code is an add-on code to be used in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 9331,

93350, 93351. As such, this code does not require separate review


AIM Provider Portal

866-666-077693325 This code is an add-on code to be used in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 93317,

93350, 93351. As such, this code does not require separate review


AIM Provider Portal

866-666-077693350 Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise and/or

pharmacologically induced stress, with interpretation and report


AIM Provider Portal

866-666-077693351 Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise and/or

pharmacologically induced stress, with interpretation and report; including performance of continuous

electrocardiographic monitoring with physician supervision


AIM Provider Portal

866-666-077693352 This code is an add-on code to be used in conjunction with 93350, 93351. As such, this code does not require

separate review


AIM Provider Portal

866-666-077693590 Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812795805 Mult Sleep Latency; recording/interpretation; mult 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812795807 Sleep Study, 3 or More Parameters Other Than Staging 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812795808 Polysomnography; Sleep Staging with 1 to 3 Additional Parameters 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812795810 Polysomnography; Sleep Staging with 4 or More Parameters 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812795811 Polysomnography; Sleep Staging With >3 Addit Parameters, W Cpap, Attended 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812795951 Monit/Lateraliz Seiz EEG & Video 24 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812796101 Psych testing with interpretation & report, per hour Optum Behavioral Health


844-884-185596102 Psych testing with interpretation & report, per hour Optum Behavioral Health


844-884-1855































Code: Description: Effective Date: Who to Contact for Review:96103 Psych testing with interpretation & report, per hour Optum Behavioral Health


844-884-185596105 Assessment of aphasia Optum Behavioral Health


844-884-185596110 Developmental testing, limited, with interpretation & report Optum Behavioral Health


844-884-185596111 Developmental testing, extended, with interpretation & report Optum Behavioral Health


844-884-185596150 Health & behavioral assessment Optum Behavioral Health














844-884-185597605 Negative Pressure Wound Therapy, Per Session; Total Area </= 50 Sq Cm 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812797606 Negative Pressure Wound Therapy, Per Session; Total Area > 50 Sq Cm 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812797607 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable

medical equipment including provision of exudate management collection


Provider Portal

855-339-8127








































Code: Description: Effective Date: Who to Contact for Review:97608 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable

medical equipment including provision of exudate management collection


Provider Portal

855-339-812799183 Physician Attendance and Supervision of Hyperbaric Oxygen Therapy; Per Session 05-01-2018 Premera Blue Cross

Provider Portal

855-339-812799408 Alcohol and/or substance abused structured screening and brief intervention services (15-30 min) Optum Behavioral Health


844-884-185599409 Alcohol and/or substance abused structured screening and brief intervention services (30 min or more) Optum Behavioral Health


844-884-185599510 Home Visit for Individual, Family, or Marriage Counseling Optum Behavioral Health


844-884-18550051T Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270095T Removal of total disc arthroplasty, anterior approach; each additional interspace 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270169T Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including

computerized stereotactic planning and burr hole(s).


Provider Portal

855-339-81270182T HDR Electronic Brachytherapy Per Fraction 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270182T HDR Electronic Brachytherapy Per Fraction 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270282T Percutaneous Or Open Implantation Of Neurostimulator Electrode Array(s), Subcutaneous; For Trial 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270282T Percutaneous Or Open Implantation Of Neurostimulator Electrode Array(s), Subcutaneous; For Trial 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270284T Revision Or Removal Of Pulse Generator Or Electrodes Including Addition Of New Electrodes, When Performed 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270284T Revision Or Removal Of Pulse Generator Or Electrodes Including Addition Of New Electrodes, When Performed 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127































Code: Description: Effective Date: Who to Contact for Review:0295T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and

storage; includes recording, scanning analysis with report, rev


Provider Portal

855-339-81270295T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and

storage; includes recording, scanning analysis with report, rev


Provider Portal


storage; recording (includes connection and initial recording)


Provider Portal


storage; recording (includes connection and initial recording)


Provider Portal


storage; scanning analysis with report


Provider Portal


storage; scanning analysis with report


Provider Portal


storage; review and interpretation


Provider Portal

855-339-81270359T Behavior identification assessment, by the physician or other qualified health care professional, face- to-face with

patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral

history, patient observation and caregiver interview, interpretation of test results, discussion of findings and

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


Provider Portal

855-339-8127

0360T Observational behavioral follow- up assessment, includes physician or other qualified health care professional

direction w/ interpretation and report, administered by one technician; first 30 minutes of tech time, face-to-face

w/patient


Provider Portal

855-339-81270361T Observational behavioral follow- up assessment, includes physician or other qualified health care professional

direction with interpretation and report, administered by one technician; each additional 30 minutes of technician

time, face-to-face with the patient


Provider Portal

855-339-8127

0362T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction

with interpretation and report, administered by physician or other qualified health care professional with the

assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient


Provider Portal

855-339-8127

0363T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction

with interpretation and report, administered by physician or other qualified health care professional with the

assistance of one or more technicians; each additional 30 minutes of technician(s) time, face- to-face with the

patient


Provider Portal

855-339-8127

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

minutes of technician time


Provider Portal

855-339-81270365T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each

additional 30 minutes of technician time


Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:0367T Group adaptive behavior treatment by protocol, administered by technician, face- to-face with two or more

patients; each additional 30 minutes of technician time


Provider Portal

855-339-8127

0368T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care

professional with one patient; first 30 minutes of patient

face-to- face time


Provider Portal

855-339-81270369T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care

professional with one patient; each additional 30 minutes of patient face-to-face time


Provider Portal

855-339-81270370T Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional

(w/o patient present)


Provider Portal

855-339-81270371T Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health

care professional (without the patient present)


Provider Portal

855-339-81270372T Adaptive behavior treatment social skills group, administered by physician or other qualified health care

professional face-to- face with multiple patients


Provider Portal

855-339-81270373T Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe

maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient


Provider Portal

855-339-81270374T Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe

maladaptive behavior(s); each additional 30 minutes of technicians' time face-to-face with patient (List separately in

addition to code for primary


Provider Portal

855-339-81270438T Transperineal placement of biodegradable material, peri- prostatic (via needle), single or multiple, includes image

guidance


Provider Portal

855-339-81270439T Myocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or

viability (List separately

in addition to code for primary procedure)


Provider Portal

855-339-81270440T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270441T Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270442T Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial

plexus, pudendal nerve)


Provider Portal

855-339-8127

0443T Real time spectral analysis of prostate tissue by fluorescence spectroscopy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127











































Code: Description: Effective Date: Who to Contact for Review:0444T Initial placement of a drug- eluting ocular insert under one or more eyelids, including fitting, training, and insertion,

unilateral or bilateral


Provider Portal

855-339-81270445T Subsequent placement of a drug- eluting ocular insert under one or more eyelids, including re-training, and removal

of existing insert, unilateral or bilateral


Provider Portal

855-339-81270451T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system,

endovascular approach, and programming of sensing and therapeutic parameters; complete system

(counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and

subcutaneous electrodes)


Provider Portal

855-339-8127

0452T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system,

endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device

and vascular hemostatic seal


Provider Portal

855-339-8127


endovascular approach, and programming of sensing and therapeutic

parameters; mechano-electrical skin interface


Provider Portal

855-339-8127


endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous

electrode


Provider Portal

855-339-8127

0462T Programming device evaluation (in person) with iterative adjustment of the implantable mechano- electrical skin

interface and/or external driver to test the function of the device and select optimal permanent programmed values

with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day


Provider Portal

855-339-8127

0463T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and

disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day


Provider Portal

855-339-81270464T Visual evoked potential, testing for glaucoma, with interpretation and report 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-81270497T Ambulatory Event Monitor 08-16-2018 Premera Blue Cross

Provider Portal

855-339-81270498T Ambulatory Event Monitor 08-16-2018 Premera Blue Cross

Provider Portal

855-339-81270501T Noninvasive estimated coronary fractional flow reserve (FFR) from coronary CTA data using computation fluid

dynamics physiologic simulation software analysis of functional data to assess severity of coronary artery disease;

data prep and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of

estimated FFR model, w/ anatomical data review in comparison w/ estimated FFR model to reconcile discordant

data, interpretation and report


AIM Provider Portal

866-666-0776






















Code: Description: Effective Date: Who to Contact for Review:0502T Data preparation and transmission 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-07760503T Analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of

estimated FFR model


AIM Provider Portal

866-666-07760504T Anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and

report


AIM Provider Portal

866-666-077627096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including

arthrography when performed


AIM Provider Portal

866-666-077662320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other

solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or

subarachnoid, cervical or thoracic; without imaging guidance


AIM Provider Portal

866-666-0776

62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other


subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)


AIM Provider Portal

866-666-0776



subarachnoid, lumbar or sacral (caudal); without imaging guidance


AIM Provider Portal

866-666-0776



subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)


AIM Provider Portal

866-666-0776

64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophysial) joint (or nerves innervating that

joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level


AIM Provider Portal

866-666-077664491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophysial) joint (or nerves innervating that

joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code

for primary procedure)


AIM Provider Portal

866-666-077664492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that

joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately

in addition to code for primary procedure)


AIM Provider Portal


joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level


AIM Provider Portal


joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for

primary procedure)


AIM Provider Portal

866-666-0776








































Code: Description: Effective Date: Who to Contact for Review:64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that

joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in



AIM Provider Portal

866-666-077664510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077664520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-077696116* Neurobehavioral status exam, per hr psychologist/physician time, patient time and interpretation/report time (If

mbr has behavioral health Dx- please contact Optum for review.)*


Provider Portal

855-339-8127



844-884-185596118* Neuropsychological testing, per hr psychologist/physician time, patient time and interpretation/ report time (If mbr

has behavioral health Dx- please contact Optum for review.)*


Provider Portal

855-339-8127



844-884-185596119* Neuropsych testing, qualified health care professional interp& report,admin by technician, per hr tech time, face-to-

face (If mbr has behavioral health Dx- please contact Optum for review.)*


Provider Portal

855-339-8127



844-884-185596120* Neuropsychological testing, administered by a computer, w qualified health care professional interpretation and

report (If mbr has behavioral health Dx- please contact Optum for review.)*


Provider Portal

855-339-8127



844-884-1855A4290 Sacral nerve stimulation test lead, each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127A7025 High Frequency Chest Wall Oscillation System Vest, Replacement For Use 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127













Code: Description: Effective Date: Who to Contact for Review:A7026 High Frequency Chest Wall Oscillation System Hose, Replacement For Use 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127A9276 Disposable sensor, CGM sys 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127A9277 External transmitter, CGM 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127A9278 External receiver, CGM sys 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C1767 Generator, neurostimulator (implantable), non-rechargeable 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C1778 Lead, neurostimulator (implantable) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C1816 Receiver and/or transmitter, neurostimulator (implantable) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C1883 Adapter/extension, pacing lead or neurostimulator lead (implantable) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C1889 Implantable/insertable device for device intensive procedure, not otherwise classified 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C2614 Probe, Percutaneous Lumbar Discectomy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C2616 Brachytherapy seed, yttrium-90 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C2698 Brachytherapy source, stranded, not otherwise specified, per source 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127C2699 Brachytherapy source, non- stranded, not otherwise specified, per source 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:C9298 Injection, ocriplasmin, 0.125 mg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0470 Respiratory assist device, bi-level pressure capability, without back- up rate feature, used with noninvasive

interface, eg, nasal or facial mask (intermittent assist device with continous positive airway pressure device)


Provider Portal

855-339-8127E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface,

EG nasal or facial mask (intermittent assist device with continuous positive pressure device)


Provider Portal

855-339-8127E0483 High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, custom fabricated 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0601 Continuous positive airway pressure (CPAP) device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0616 Implantable cardiac event recorder with memory, activator and programmer 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0617 External defibrillator with integrated electrocardiogram analysis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0627 Seat lift mechanism incorporated into a combination lift-chair mechanism 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0629 Separate seat lift mechanism for use with patient owned furniture; non-electric 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0676 Intermittent limb compression device (includes all accessories), not otherwise specified 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0747 Osteogenesis stimulator, electrical, non-invasive, other than spinal applications 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:E0749 Osteogenesis stimulator, electrical, surgically implanted 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0765 FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0784 External ambulatory infusion pump, insulin 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E0988 Manual Wheelchair Accessory, Lever-Activated, Wheel Drive, Pair 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete

system, any type, each


Provider Portal

855-339-8127E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1801 SPS elbow device w/ or w/o range of motion adjustment, includes all components and accessories 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1802 Dynamic Adjustable Forearm Pronation/Supination Device, Inc Soft Inter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1806 SPS wrist device w/ or w/o range of motion adjustment, includes all components and accessories 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1811 SPS knee device w/ or w/o range of motion adjustment, includes all components and accessories 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1812 Dynamic knee, extension/flexion device with active resistance control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:E1818 SPS forearm pronation/supination device w/ or w/o range of motion adjustment, includes all components and

accessories


Provider Portal

855-339-8127E1820 Replacement soft interface material, dynamic adjustable extension/flexion device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2359 Power Wheelchair Accessory, Group 34 Sealed Lead Acid Battery, Each (E.G. Gel Cell, Absorbed Glassmat) 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2378 Power actuator replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2402 Negative pressure wound therapy electrical pump, stationary or portable 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2500 Speech generating device, digitized speech, using pre- recorded messages, 8 min. or less 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2502 Speech generating device, digitized speech, using pre- recorded messages, 8-20 min. 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2504 Speech generating device, digitized speech, using pre- recorded messages, 20-40 min. 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2506 Speech generating device, digitized speech, using pre- recorded messages, over 40 min. 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2508 Speech generating device, synthesized speech, requiring message formulation by spelling 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2510 Speech generating device, synthesized speech, permitting multiple methods 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2511 Speech generating software program, for personal computer or personal digital assistant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:E2512 Accessory for speech generating device, mounting system 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2599 Accessory for speech generating device, not otherwise classified 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2622 Adj skin pro w/c cus wd<22in 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2623 Adj skin pro wc cus wd>=22in 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2624 Adj skin pro/pos cus<22in 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127E2625 Adj skin pro/pos wc cus>=22 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15

minutes


Provider Portal

855-339-8127G0238 Therapeutic procedures to improve respiratory function, other than described by G0237, one-on-one, face-to-face,

per 15 minutes (includes monitoring)


Provider Portal

855-339-8127G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, 2

or more individuals (incl monitoring)


Provider Portal

855-339-8127G0248 Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic

atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a

physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood

sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to

perform testing and report results


Provider Portal

855-339-8127

G0249 Provision Of Test Materials And Equipment For Home Inr Monitoring To Patient 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127

G0250 Physician Review, Interpretation And Patient Management Of Home Inr Test 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127



















Code: Description: Effective Date: Who to Contact for Review:G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127G0297 Low dose CT scan (LDCT) for lung cancer screening 01-01-2018 AIM Specialty Health

AIM Provider Portal

866-666-0776G0339 Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session

or first session of fractionated treatment


AIM Provider Portal

866-666-0776G0340 Image-guided robotic linear accelerator based stereotactic radiosurgery, delivery including collimator changes and

custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions; maximum five

sessions per course of treatment


AIM Provider Portal

866-666-0776G0341 Percutaneous islet cell trans 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127G0342 Laparoscopy islet cell trans 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127G0343 Laparotomy islet cell transp 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127G0424‡ Pulmonary rehab w exercise (prior auth required for mbrs with Premera MA (HMO), Classic (HMO), Classic Plus

(HMO), or Total Health (HMO) only)


Provider Portal

855-339-8127G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active

antiretroviral therapy)


Provider Portal

855-339-8127G0455 Fecal microbiota prep instil 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127G0500 Moderate sedation services provided by the same physician or other qualified health care professional performing a

gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained

observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15

minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as

appropriate)


Provider Portal

855-339-8127

G6001 Ultrasonic guidance for placement of radiation therapy fields 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776G6002 Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy 01-01-2019 AIM Specialty Health

AIM Provider Portal

866-666-0776































Code: Description: Effective Date: Who to Contact for Review:G6003 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no

blocks: up to 5 MeV


AIM Provider Portal

866-666-0776G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no

blocks: 6-10 MeV


AIM Provider Portal


blocks: 11-19 MeV


AIM Provider Portal


blocks: 20 MeV or greater


AIM Provider Portal

866-666-0776G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of

multiple blocks: up to 5 MeV


AIM Provider Portal


multiple blocks: 6-10 MeV


AIM Provider Portal


multiple blocks: 11-19 MeV


AIM Provider Portal


multiple blocks: 20 MeV or greater


AIM Provider Portal

866-666-0776G6011 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges,

rotational beam, compensators, electron beam; up to 5 MeV


AIM Provider Portal


rotational beam, compensators, electron beam; 6-10 MeV


AIM Provider Portal


rotational beam, compensators, electron beam; 11-19 MeV


AIM Provider Portal


rotational beam, compensators, electron beam; 20 MeV or greater


AIM Provider Portal

866-666-0776G6017 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D

positional tracking, gating, 3D surface tracking), each fraction of treatment


AIM Provider Portal

866-666-0776G9143 Warfarin respon genetic test 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127








































Code: Description: Effective Date: Who to Contact for Review:G9708 Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is

evidence of a right and a left unilateral mastectomy


Provider Portal

855-339-8127G9748 Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127G9750 Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127H0001 Alcohol and/or drug assessment Optum Behavioral Health


844-884-1855H0002 Behavioral health screening to determine eligibility for admission to treatment program Optum Behavioral Health


844-884-1855H0004 Behavioral health counseling and therapy\(15 min) Optum Behavioral Health


844-884-1855H0005 Alcohol and/or drug services; group counseling by a clinician Optum Behavioral Health


844-884-1855H0031 Mental health assessment, by non- physician, per hour (Used as ABA Code) Optum Behavioral Health


844-884-1855H0032 Mental health service plan development by non-physician, per hour (Used as ABA Code) Optum Behavioral Health


844-884-1855H0033 Oral medication administration, direct observation Optum Behavioral Health


844-884-1855H0046 Mental Health Services, Not Otherwise Specified (60 Min) Optum Behavioral Health


844-884-1855H0047 Alcohol and/or other drug abuse services, not otherwise specified Optum Behavioral Health


844-884-1855H2010 Comprehensive Medication Services (15 min) Optum Behavioral Health


844-884-1855H2011 Crisis Intervention Service (15 min) Optum Behavioral Health


844-884-1855








































Code: Description: Effective Date: Who to Contact for Review:H2012 Behavioral Health Day Treatment, per hour (Used as ABA Code) Optum Behavioral Health


844-884-1855H2014 Skills Training and Development, per 15 minutes (Used as ABA Code) Optum Behavioral Health


844-884-1855H2014 HA MH Skills Training and Development per 15 min; Social Skills Group (multi child & staff); child/adolescent program

per 15 min



844-884-1855H2019 Therapeutic behavioral services; per 15 min (Used as ABA Code) Optum Behavioral Health


844-884-1855H2021 In-Home Intervention/Community- Based Wrap Around Services (Used as ABA Code) Optum Behavioral Health


844-884-1855H2027 HA MH Psychoeducational Services; Social Skills Group (multi child & staff); per 15 min; child/adolescent program –

Definition applicable to Pennsylvania (PA)

Providers Only (Used as ABA Code)



844-884-1855J0129 Orencia 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0178 Eylea 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J0180† Fabrazyme 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J0220 Myozyme 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0221† Lumizyme 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J0256 Aralast 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0256 Aralast NP 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0256 Prolastin-C 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127

























Code: Description: Effective Date: Who to Contact for Review:J0256 Zemaira 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0257 Glassia 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0585 Botox 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J0586 Dysport 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J0587 Myobloc 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J0588 Xeomin 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J0717 Cimzia 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0775 Xiaflex 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J0897 Prolia 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1300 Soliris 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1322 Vimizim 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1325 Flolan Injection 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1325 Veletri 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1428 Exondys 51 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127










Code: Description: Effective Date: Who to Contact for Review:J1458† Naglazyme 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1459† Privigen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1555 Cuvitru 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1556† Bivigam 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1557† Gammaplex 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1559 Hizentra 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1561† Gammaked 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1561† Gamunex-C 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1562 Vivaglobin 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1566† Carimune 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1566† Gammagard S/D 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1568† Octagam 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1569† Gammagard 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1572† Flebogamma 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127
















Code: Description: Effective Date: Who to Contact for Review:J1575† HyQvia 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1599 Inj IVIG non-lyophilized NOS, 500 mg 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1602 Simponi Aria 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1743 Elaprase 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1745 Remicade 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J1786† Cerezyme 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J1931† Aldurazyme 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J2182 Nucala 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J2326 Spinraza 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J2357† Xolair 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J2503 Macugen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J2504† Adagen 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J2507 Krystexxa 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J2778 Lucentis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127
















Code: Description: Effective Date: Who to Contact for Review:J2786 Cinqair 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J2796 Nplate 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J2840 Kanuma 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J2860 Sylvant 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J3060 Elelyso 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J3262 Actemra 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J3285 Remodulin 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J3358 Stelara 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J3380 Entyvio 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J3385 VPRIV 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J3590 Luxturna 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J3590 Fasenra 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J3590 Trogarzo 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J7686 Tyvaso 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127







Code: Description: Effective Date: Who to Contact for Review:J9022 Tecentriq 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J9023 Bavencio 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J9042 Adcetris 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J9047 Kyprolis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9176 Empliciti 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9205 Onivyde 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9228† Yervoy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9271† Keytruda 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9299 Opdivo 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9308 Cyramza 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9352 Yondelis 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127J9999 Rituxan Hycela 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127J9999 Imfinzi 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127K0010 Stnd Wt Frame Power Whlchr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127










Code: Description: Effective Date: Who to Contact for Review:K0011 Stnd Wt Pwr Whlchr W Control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0012 Ltwt Portbl Power Whlchr 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0013 Custom Power Whlchr Base 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0014 Other Power Whlchr Base 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0553 Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 unit of

service = 1 month's supply


Provider Portal

855-339-8127K0554 Receiver (Monitor), dedicated, for use with therapeutic continuous glucose monitor system 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0743 Suction pump, home model, portable, for use on wounds 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0744 Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 square inches or less 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0745 Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches

but less than or equal to 48 square inches


Provider Portal

855-339-8127K0746 Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square

inches


Provider Portal

855-339-8127K0800 Power operated vehicle, grp 1 standard, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0801 Power operated vehicle, grp 1 heavy duty, patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0802 Power operated vehicle, grp 1 very heavy duty, patient weight cap 451- 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127



















Code: Description: Effective Date: Who to Contact for Review:K0806 Power operated vehicle, grp 2 standard, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0807 Power operated vehicle, grp 2 heavy duty, patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0808 Power operated vehicle, grp 2 very heavy duty, patient weight cap 451- 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0812 Power operated vehicle, not otherwise classified 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0813 Power wheelchair, grp 1 standard, portable, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0814 Power wheelchair, grp 1 standard, portable, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0815 Power wheelchair, grp 1 standard, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0816 Power wheelchair, grp 1 standard, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0820 Power wheelchair, grp 2 standard, portable, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0821 Power wheelchair, grp 2 standard, portable, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0822 Power wheelchair, grp 2 standard, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0823 Power wheelchair, grp 2 stnd, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0824 Power wheelchair, grp 2 heavy duty, sling/solid seat/back, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0825 Power wheelchair, grp 2 heavy duty, captains chair, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:K0826 Power wheelchair, grp 2 very heavy duty, sling/solid seat/back, patient weight cap 451- 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0827 Power wheelchair, grp 2 very heavy duty, captains chair, patient weight cap 451-600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0828 Power wheelchair, grp 2 extra heavy duty, sling/solid seat/back, patient weight cap 601 lbs or more 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0829 Power wheelchair, grp 2 extra heavy duty, captains chair, patient weight cap 601 lbs or more 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0835 Power wheelchair, grp 2 stnd, single power option, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0836 Power wheelchair, grp 2 stnd, single power option, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0837 Power wheelchair, grp 2 heavy duty, single power option, sling/solid seat/back, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0838 Power wheelchair, grp 2 heavy duty, single power option, captains chair, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0839 Power wheelchair, grp 2 very heavy duty, single power option, sling/solid seat/back, patient weight cap 451-

600 lbs


Provider Portal

855-339-8127K0840 Power wheelchair, grp 2 extra heavy duty, single power option, sling/solid seat/back, patient weight cap up to and

incl 300 lbs


Provider Portal

855-339-8127K0841 Power wheelchair, grp 2 stnd, mult power option, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0842 Power wheelchair, grp 2 stnd, mult power option, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0843 Power wheelchair, grp 2 heavy duty, mult power option, sling/solid seat/back, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0848 Power wheelchair, grp 3 stnd, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:K0849 Power wheelchair, grp 3 stnd, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal


Provider Portal

855-339-8127K0851 Power wheelchair, grp 3 heavy duty, captains chair, patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0852 Power wheelchair, grp 3 very heavy duty, sling/solid seat/back, patient weight cap 451- 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0853 Power wheelchair, grp 3 very heavy duty, captains chair, patient weight cap 451-600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0854 Power wheelchair, grp 3 extra heavy duty, sling/solid seat/back, patient weight cap 601 lbs or more 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0855 Power wheelchair, grp 3 extra heavy duty, captains chair, patient weight cap 601 lbs or more 05-01-2018 Premera Blue Cross

Provider Portal


Provider Portal


Provider Portal

855-339-8127K0858 Power wheelchair, grp 3 heavy duty, single power option, sling/solid seat/back, patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0859 Power wheelchair, grp 3 heavy duty, single power option, captains chair, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0860 Power wheelchair, grp 3 very heavy duty, single power option, sling/solid seat/back, patient weight cap 451-600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0861 Power wheelchair, grp 3 stnd, mult power option, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0862 Power wheelchair, grp 3 heavy duty, mult power option, sling/solid seat/back, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:K0863 Power wheelchair, grp 3 very heavy duty, mult power option, sling/solid seat/back, patient weight cap 451- 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0864 Power wheelchair, grp 3 extra heavy duty, mult power option, sling/solid seat/back, patient weight cap 601 lbs or

more


Provider Portal

855-339-8127K0868 Power wheelchair, grp 4 stnd, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0869 Power wheelchair, grp 4 stnd, captains chair, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal


Provider Portal

855-339-8127K0871 Power wheelchair, grp 4 very heavy duty, sling/solid seat/back, patient weight cap 451- 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal


Provider Portal


Provider Portal

855-339-8127K0879 Power wheelchair, grp 4 heavy duty, single power option, sling/solid seat/back, patient weight cap 301-450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0880 Power wheelchair, grp 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451- 600 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0884 Power wheelchair, grp 4 stnd, mult power potion, sling/solid seat/back, patient weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0885 Power wheelchair, grp 4 stnd, mult power option, captains chair, weight cap up to and incl 300 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0886 Power wheelchair, grp 4 heavy duty, mult power option, sling/solid seat/back, patient weight cap 301- 450 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0890 Power wheelchair, grp 5 ped, single power option, sling/solid seat/back, patient weight cap up to and incl 125 lbs 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:K0891 Power wheelchair, grp 5 pediatric, mult power option, sling/solid seat/back, patient weight cap up to and incl 125

lbs


Provider Portal

855-339-8127K0898 Power wheelchair, not otherwise classified 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127K0899 Power mobility device, not coded by DME PDAC or does not meet criteria 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5610 Addition to lower extremity, endoskeletal system, above knee, hydracadence system 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5613 Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with hydraulic

swing


Provider Portal

855-339-8127L5614 Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with pneumatic

swing


Provider Portal

855-339-8127L5722 Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5724 Addition, exoskeletal knee-shin system, single axis, fluid swing phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5726 Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5728 Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5780 Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:L5824 Addition, endoskeletal knee-shin system, single axis, fluid swing phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5826 Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity

frame


Provider Portal

855-339-8127L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5840 Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase control 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5848 Addition to endoskeletal knee- shin system, fluid stance extension, dampening feature, with or without adjustability 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L5856 Addition to lower extremity prosthesis, endoskeletal knee- shin system, microprocessor control

feature, swing and stance


Provider Portal

855-339-8127L5857 Addition to lower extremity prosthesis, endoskeletal knee- shin system, microprocessor control

feature, swing phase only,


Provider Portal

855-339-8127L5858 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance

phase only


Provider Portal

855-339-8127L5859 Addition to lower extr prosthesis, endoskeletal knee-shin sys, powered/ programmable flex/exten assist control,

incl any type motor(s)


Provider Portal

855-339-8127L5961 Addition, endoskeletal sys, polycentric hip jnt, pneum or hydraulic contrl, rotation contrl, w/wo flex and/or ext

contrl


Provider Portal

855-339-8127L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control,

includes power source


Provider Portal

855-339-8127L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with

removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device,

excludes terminal device(s)


Provider Portal

855-339-8127L6628 Upper extremity addition, quick disconnect hook adapter, otto bock or equal 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, otto bock or equal 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6632 Upper extremity addition, latex suspension sleeve, each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6680 Upper extremity addition, test socket, wrist disarticulation or below elbow 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6687 Upper extremity addition, frame type socket, below elbow or wrist disarticulation 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6810 Addition to terminal device, precision pinch device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6880 Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination

of grasp patterns, includes motor(s)


Provider Portal

855-339-8127L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and

adjustment


Provider Portal

855-339-8127L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal

electrodes, cables, two batteries and one charger, myoelectronic control of terminal device


Provider Portal

855-339-8127L6935 Below elbow, external power, self- suspended inner socket, removable forearm shell, otto bock or equal electrodes,

cables, two batteries

and one charger, myoelectronic control of terminal device


Provider Portal

855-339-8127

L6945 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges,

forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal

device


Provider Portal

855-339-8127

L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto

bock or equal electrodes, cables, two batteries and one charger, myoelectronic control

of terminal device


Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:L6965 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead,

humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger,

myoelectronic control of terminal device


Provider Portal

855-339-8127

L6975 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral

section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger,

myoelectronic control of terminal device


Provider Portal

855-339-8127

L7007 Electric hand, switch or myoelectric controlled, adult 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7008 Electric hand, switch or myoelectric, controlled, pediatric 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7009 Electric hand, switch or myoelectric, controlled, pediatric 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7045 Electric hook, switch or myoelectric controlled, pediatric 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7180 Electronic elbow, microprocessor sequential control of elbow and terminal device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7181 Electronic elbow, microprocessor simultaneous control of elbow and terminal device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7190 Electronic elbow, adolescent, variety village or equal, myoelectronically controlled 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7191 Electronic elbow, child, variety village or equal, myoelectronically controlled 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7368 Lithium ion battery charger, replacement only 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber

or equal)


Provider Portal

855-339-8127L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:L8465 Prosthetic shrinker, upper limb, each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8465 Prosthetic shrinker, upper limb, each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8614 Cochlear device, includes all internal and external components 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8614 Cochlear device, includes all internal and external components 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8615 Headset/headpiece for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8615 Headset/headpiece for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8616 Microphone for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8616 Microphone for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8617 Transmitting coil for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8617 Transmitting coil for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8618 Transmitter cable for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8618 Transmitter cable for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8619 Cochlear implant, external speech processor and controller, integrated system, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8621 Zinc air battery for use w/ cochlear implant device, replacement, each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:L8622 Alkaline battery for use w/ cochlear implant device, any size, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8627 Cochlear implant, external speech processor, component, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8628 Cochlear implant, external controller component, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8679 Implantable neurostimulator, pulse generator, any type 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8680 Implantable neurostimulator electrode, each 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8681 Pt prgrm for implt neurostim 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8682 Implt neurostim radiofq rec 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8683 Radiofq trsmtr for implt neu 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and

bladder management, replacement


Provider Portal

855-339-8127L8685 Implt nrostm pls gen sng rec 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8686 Implt nrostm pls gen sng non 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8687 Implt nrostm pls gen dua rec 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8688 Implt nrostm pls gen dua non 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:L8689 External recharging system 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8690 Auditory osseointegrated device, includes all internal and external components 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127L8695 External recharg sys extern 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127M0300 IV Chelationtherapy 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q0478 Power adapter, combo vad 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q0506 Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q0507 Misc supply or accessory for use with an external ventricular assist device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q0509 Misc supply or accessory for use w/any implanted ventricular assist device for which pymt not made under

Medicare Part A


Provider Portal

855-339-8127Q2026 Radiesse Injection 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q2028 Sculptra Injection 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q2040 Kymriah 11-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q2041 Yescarta 11-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4101 Skin substitute, Apligraf, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127



















Code: Description: Effective Date: Who to Contact for Review:Q4102 Skin substitute, Oasis Wound Matrix, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4105 Skin substitute, Integra Dermal Regeneration Template (DRT), per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4106 Skin substitute, Dermagraft, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4107 Skin substitute, Graftjacket, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4110 Skin substitute, Primatrix, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4114 Integra flowable wound matrix, injectable, 1 cc 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4121 Theraskin 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4124 Oasis ultra tri-layer wound matrix, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4131 Epifix 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4166 Cytal, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4167 Truskin, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4168 Amnioband, 1 mg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4169 Artacent wound, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4170 Cygnus, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127






















Code: Description: Effective Date: Who to Contact for Review:Q4171 Interfyl, 1 mg 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4172 Puraply or puraply am, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4173 Palingen or palingen xplus, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4174 Palingen or promatrx, 0.36 mg per 0.25 cc 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q4175 Miroderm, per square centimeter 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127Q5103 Inflectra 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127Q5104 Renflexis 01-01-2019 Premera Blue Cross

Provider Portal

855-339-8127S0317 Disease management program; per diem 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127S1040 Cranial Remodeling Orthosis, Rigid W/Soft Interface Material 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127S2340 Chemodenervation Of Abductor 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127S2341 Chemodenervation of adductor muscle(s) of vocal cord 05-01-2018 Premera Blue Cross

Provider Portal

855-339-8127S9473‡ Pulmonary Rehabilitation Prgm (prior auth required for mbrs with Premera MA (HMO), Classic (HMO), Classic

Plus (HMO), or Total Health (HMO) only)


Provider Portal

855-339-8127S9485 Crisis intervention mental health services, per diem Optum Behavioral Health


844-884-1855



















Documents

Medicare Advantage - Healthx