Single source preauthorization list
This information is not a guarantee of payment.
Benefits are subject to limitations in a member’s Benefits Booklet (Certificate of Coverage) and the member’s eligibility status.
The information being provided is based on information currently available in Capital Blue Cross' files.
Payment or processing of actual claims is subject to a determination about the member’s benefits and eligibility at the time of processing and a determination that the services are medically necessary and appropriate. Other factors, including, but not limited to, outstanding or in-process claims, may affect actual totals. Information may change due to coverage alterations or cancellation. All information in our files is proprietary and confidential to Capital Blue Cross and is to be used only for its intended purposes.
Do not disclose
- CPT and revenue code descriptions are subject to copyright and therefore not included on the external single source preauthorization code list.
- Preauthorization is required for the following list of items that are not necessarily listed separately by code: all inpatient admissions or services/items that are considered by Capital Blue Cross medical policy to be investigational and possibly cosmetic.
- Preauthorization is required for non-routine maternity admissions, including preterm labor, maternity complications, and newborns requiring continued hospitalization after the mother is discharged.
- Preauthorization does not generally apply to services/items that are specifically excluded from coverage under the member’s Benefits Booklet (Certificate of Coverage). Therefore, these items may not appear on the preauthorization list.
- All services that are considered investigational or possibly cosmetic require documentation from the member’s medical record to ensure the item/service is medically necessary. Certain services may also require submission of photographs and are noted below.
- Please refer to Capital Blue Cross’ Medical Policy (or its delegated vendor) for medical necessity information.
- Applied Behavioral Analysis (ABA) services requiring preauthorization are listed below on the Single Source Preauthorization Code list. Providers should submit the appropriate CPT codes listed below and no longer use H0032, H2014, H2019, H2020, H2021, and H2022 codes for ABA assessment or treatment.
- Administrative services only (ASO)/ Self-funded groups: Please note that some self-funded employer groups may customize their plans with different benefits and preauthorization requirements. The provider can check authorization requirements at the service code level via the authorization portal.
- Subject to the exceptions listed in the General Preauthorization Overview, codes requiring preauthorization are listed by code in this form.
| Code | HCPCS and dental code description | Preauthorization category | Type of care | Comments | Commercial | Medicare Advantage |
|---|---|---|---|---|---|---|
|
0001U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0016U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0017U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0018U |
|
Investigational and experimental procedures |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0019U |
|
Investigational and experimental procedures |
Lab/Genetic testing |
For Medicare covered if medically necessary |
Yes |
Yes |
|
0022U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0023 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0023U |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0026U |
|
Diagnostic services/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0027U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0029U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0034U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0035U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0037U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0040U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0042T |
|
Diagnostic services: CT scans |
X-ray/Imaging - Cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
0046U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0047U |
|
Diagnostic services: Genetic testing |
Investigational lab/Genetic testing |
Non covered for commercial product |
Yes |
Yes |
|
0049U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0069U |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0075T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0076T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0084U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0094U |
|
Diagnostic services: Genetic testing |
Lab/Genetic Testing |
|
Yes |
Yes |
|
0111U |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0138U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0152U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0153U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0154U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0155U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0157U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0158U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0159U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0160U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0161U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0162U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0165T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0169U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0171U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0172U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0173U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0177U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0180U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0181U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0182U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0183U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0184U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0185U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0186U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0187U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0188U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0189U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0190U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0191U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0192U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0193U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0194U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0195U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0196U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0197U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0198U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0199U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0200T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0200U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0201T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0201U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0202T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0209U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0245U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0253T |
|
Outpatient surgery for select procedures |
Surgery - eye |
|
Yes |
No |
|
0286U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0212U |
|
Diagnostic services: MRI |
Diagnostic services: MRI |
|
Yes |
Yes |
|
0213U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0214U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0215U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
|
0218U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0219T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0220T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0221T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0222T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0230U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0231U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0232U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
If it does not meet the medically necessary criteria on policy then invalid |
Yes |
Yes |
|
0233U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0234U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
If it does not meet the criteria on 2.326 |
Yes |
Yes |
|
0235U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0237U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0238U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
If it does not meet criteria on policy then invalid |
Yes |
No |
|
0239U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
0250U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0252U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
0258U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0265U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0266U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0268U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0269U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0270U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0271U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0272U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0273U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0274U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0277U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0278U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0282U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0274T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0275T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0129U |
Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53) |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0276U |
Hematology (inherited thrombocytopenia), genomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0314U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0317U |
Oncology (lung cancer), four-probe fish (3q29, 3p22.1, 10q22.3, 10cen) assay, whole blood, predictive algorithm generated evaluation reported as decreased or increased risk for lung cancer |
Diagnostic services: genetic testing |
Diagnostic services: genetic testing |
|
Yes |
Yes |
|
0318U |
Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood |
Diagnostic services: genetic testing |
Diagnostic services: genetic testing |
|
Yes |
Yes |
|
0326U |
|
Diagnostic services: genetic testing |
Diagnostic services: genetic testing |
|
Yes |
Yes |
|
0334U |
|
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0362T |
|
Investigational and experimental procedures |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
0364U |
|
Diagnostic Services: Genetic Testing |
Diagnostic Services: Genetic Testing |
|
Yes |
Yes |
|
0373T |
|
Investigational and experimental procedures |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
0378U |
|
Diagnostic Services: Genetic Testing |
Diagnostic Services: Genetic Testing |
|
Yes |
Yes |
|
0388U |
Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection |
Diagnostic Services: Genetic Testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
0394T |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
0483T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0484T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0515T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0516T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0517T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0519T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0520T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0552 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0571T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0572T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0573T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0574T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0580T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0646T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0795T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0796T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0797T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0798T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0799T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0800T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0801T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0802T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0803T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0823T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0824T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0825T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0395T |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
0402T |
|
Outpatient Surgery For Select Procedures |
Surgery - Eye |
|
No |
Yes |
|
0408T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0417U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0449U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
No |
|
0449T |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
No |
|
0450T |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
No |
|
0461U |
Oncology, pharmacogenomic analysis of single-nucleotide polymorphism (snp) genotyping by real-time pcr of 24 genes, whole blood or buccal swab, with variant analysis, including impacted gene-drug interactions and reported phenotypes |
Diagnostic Services: Genetic Testing |
Lab/Genetic Testing |
|
Yes |
Yes |
|
0471U |
oncology (colorectal cancer), qualitative real-time pcr of 35 variants of kras and nras genes (exons 2,3,4), formalin-fixed paraffin-embedded (ffpe), predictive, identification of detected mutations |
Diagnostic Services: Genetic Testing |
Lab/Genetic Testing |
|
Yes |
Yes |
|
0473U |
oncology (solid tumor), next-generation sequencing (ngs) of dna from formalin-fixed paraffin-embedded (ffpe) tissue with comparative sequence analysis from a matched normal specimen (blood or saliva), 648 genes, interrogation for sequence variants, insertion and deletion alterations, copy number variants, rearrangements, microsatellite instability, and tumor-mutation burden |
Diagnostic Services: Genetic Testing |
Lab/Genetic Testing |
|
Yes |
Yes |
|
0474T |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
No |
|
0474U |
hereditary pan-cancer (eg, hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel of 88 genes with 20 duplications/deletions using next-generation sequencing (ngs), sanger sequencing, blood or saliva, reported as positive or negative for germline variants, each gene |
Diagnostic Services: Genetic Testing |
Lab/Genetic Testing |
|
Yes |
Yes |
|
0481U |
IDH1 (Isocitrate Dehydrogenase 1 [NADP+]), IDH2 (Isocitrate Dehydrogenase 2 [NADP+]), And TERT (Telomerase Reverse Transcriptase) Promoter (Eg, Central Nervous System [CNS] Tumors), Next-Generation Sequencing (Single-Nucleotide Variants [SNV], Deletions, And Insertions) |
Diagnostic Services: Genetic Testing |
Lab/Genetic Testing |
|
Yes |
No |
|
0483T |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
Yes |
|
0524T |
|
Reconstructive or cosmetic services: Varicose veins |
Varicose vein procedure |
|
Yes |
Yes |
|
0552T |
|
other services: laser treatment |
Wound care |
|
Yes |
Yes |
|
0570 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0571 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0572 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0579 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0580 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0581 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0582 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0583 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0589 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0590 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0624 |
|
Investigational and experimental procedures |
Investigational Supply |
Facility revenue code requires preauthorization. |
Yes |
Yes |
|
0671T |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
No |
|
0724T |
|
Diagnostic Services es: mri |
X-RAY/Imaging-mri |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
0742T |
|
Diagnostic Services es: spect |
X-RAY/Imaging-Spect |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
0784T |
|
Surgery for select procedures |
Surgery - musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
0785T |
|
Surgery for select procedures |
Surgery - musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
0786T |
|
Surgery for select procedures |
Nerve stimulator |
; |
Yes |
No |
|
0787T |
|
Surgery for select procedures |
Nerve stimulator |
; |
Yes |
No |
|
0790T |
|
Surgery for select procedures |
Surgery - musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
0861T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0862T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0863T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0905 |
|
Select outpatient behavioral health services |
Behavioral health service |
|
Yes |
Yes |
|
0906 |
|
Select outpatient behavioral health services |
Behavioral health service |
|
Yes |
Yes |
|
0912 |
|
Select outpatient behavioral health services |
Behavioral health service |
|
Yes |
Yes |
|
0913 |
|
Select outpatient behavioral health services |
Behavioral health service |
|
Yes |
Yes |
|
0913T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0914T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0915T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0916T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0917T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0918T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0919T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0920T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0921T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0922T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0923T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0924T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
0925T |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
10040 |
|
Reconstructive or cosmetic services: Acne surgery |
Surgery - skin procedure |
|
Yes |
Yes |
|
11450 |
|
Reconstructive or cosmetic services: excision/lipectomy |
Surgery-skin procedure |
|
Yes |
Yes |
|
11451 |
|
Reconstructive or cosmetic services: excision/lipectomy |
Surgery-skin procedure |
|
Yes |
Yes |
|
11920 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
11921 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
11950 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
|
11951 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
|
11952 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
|
11954 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
|
11960 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
|
11970 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
11971 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
15150 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
|
15155 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
|
15271 |
|
Other services: wound care products |
Wound care |
|
Yes |
No |
|
15273 |
|
Other services: wound care products |
Wound care |
|
Yes |
No |
|
15275 |
|
Other services: wound care products |
Wound care |
|
Yes |
No |
|
15277 |
|
Other services: wound care products |
Wound care |
|
Yes |
No |
|
15771 |
|
Reconstructive or cosmetic services: Breast procedures |
Reconstructive or cosmetic services: Augmentation and grafting |
|
Yes |
Yes |
|
15773 |
|
Surgery for select procedures |
Reconstructive or cosmetic services: |
|
Yes |
Yes |
|
15775 |
|
Reconstructive or cosmetic services: Hair transplant |
Hair transplant |
|
Yes |
Yes |
|
15776 |
|
Reconstructive or cosmetic services: Hair transplant |
Hair transplant |
|
Yes |
Yes |
|
15780 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
No |
|
15781 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
No |
|
15782 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
No |
|
15783 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
No |
|
15786 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
Yes |
|
15788 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
Yes |
|
15789 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
Yes |
|
15792 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
Yes |
|
15793 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
Yes |
|
15820 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
15821 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
15822 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
15823 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
15824 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
|
15825 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
|
15826 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
|
15828 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
|
15829 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
|
15830 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
No |
|
15832 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15833 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15834 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15835 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15836 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15837 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15838 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15839 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15876 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15877 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
No |
|
15878 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
15879 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
|
17106 |
|
Other services: Laser treatment |
Skin procedure |
|
Yes |
No |
|
17107 |
|
Other services: Laser treatment |
Skin procedure |
|
Yes |
No |
|
17108 |
|
Other services: Laser treatment |
Skin procedure |
|
Yes |
No |
|
17360 |
|
Reconstructive or cosmetic services: Acne surgery |
Skin procedure |
|
Yes |
Yes |
|
17380 |
|
Reconstructive or cosmetic services: Acne surgery |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
19296 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
19297 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
19298 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
19300 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
No |
|
19316 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19318 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
No |
|
19325 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
No |
|
19328 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19330 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19340 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
No |
|
19342 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
No |
|
19350 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
No |
|
19355 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19357 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19361 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19364 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19367 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19368 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19369 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19370 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19371 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19380 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
19396 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
No |
|
20605 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
No |
|
20974 |
|
Investigational and experimental procedures |
Bone stimulator |
|
Yes |
Yes |
|
20975 |
|
Investigational and experimental procedures |
Bone stimulator |
|
Yes |
Yes |
|
20979 |
|
Investigational and experimental procedures |
Bone stimulator |
|
Yes |
Yes |
|
20982 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
|
21073 |
|
Investigational and experimental procedures |
Investigational TMJ treatment |
|
Yes |
No |
|
21116 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
No |
|
21120 |
|
Other services: Augmentation and Grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21121 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21122 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21123 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21125 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21127 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21137 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21138 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21139 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21141 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21142 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
| 21143
|
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21145 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21146 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21147 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21150 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21151 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21154 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21155 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21159 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21160 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21172 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21175 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21179 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21180 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21181 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21182 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21183 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21184 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21188 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21193 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21194 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21195 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21196 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21198 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21199 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21206 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21208 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21209 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21210 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21215 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21230 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21235 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21240 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
No |
|
21242 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
No |
|
21243 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
No |
|
21244 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21245 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21246 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21247 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21248 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21249 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21255 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21256 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21263 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21267 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21268 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21270 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
| 21275
|
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21280 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Eye |
|
Yes |
Yes |
|
21282 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Eye |
|
Yes |
Yes |
|
21431 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21432 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21433 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21435 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21436 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
|
21740 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Chest |
|
Yes |
Yes |
|
21742 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Chest |
|
Yes |
Yes |
|
21743 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Chest |
|
Yes |
Yes |
|
22220 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22222 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22224 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22226 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22510 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22511 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22512 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22513 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22514 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22515 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22532 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22533 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22534 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22548 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22551 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22552 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22554 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22556 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22558 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22585 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22586 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22590 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22595 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22600 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22610 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22612 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22614 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22630 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22632 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22633 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22634 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22800 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22802 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22804 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22808 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22810 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22812 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22818 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22819 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22830 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22836 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
22837 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
22838 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
22849 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22856 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22857 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22858 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22860 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22861 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22862 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22864 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22865 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22867 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22868 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22869 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22870 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
22899 |
|
Surgery for select procedures |
Musculoskeletal Procedures |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23120 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23125 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23130 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23190 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23195 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23333 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23334 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23335 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23395 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23397 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23400 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23405 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23406 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23410 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23412 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23415 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23420 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23440 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23450 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23455 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23460 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23462 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23465 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23466 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23470 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23472 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23473 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23474 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23616 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23800 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
23802 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27033 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27090 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27091 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27120 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27122 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27125 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27130 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27132 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27134 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27137 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27138 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27146 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27147 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27151 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27156 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27158 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27161 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27236 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27278 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
27279 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27280 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27284 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27286 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27299 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27403 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27405 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27407 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27409 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27412 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27415 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27416 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27418 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27420 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27422 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27424 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27425 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27427 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27428 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27429 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27437 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27438 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27440 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27441 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27442 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27443 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27445 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27446 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27447 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27486 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27487 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27488 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27570 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
27580 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
28291 |
|
Hallux Rigidus Correction With Cheilectomy, Debridement And Capsular Release Of The First Metatarsophalangeal Joint; With Implant |
Outpatient Surgery For Select Procedures |
Surgery- Musculoskeletal |
Yes |
No |
|
28446 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29827 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29850 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29851 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29855 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29856 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29860 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29861 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29862 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29863 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29866 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29867 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29868 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29870 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29871 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29873 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29874 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29875 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29876 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29877 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29879 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29880 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29881 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29882 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29883 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29884 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29885 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29886 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29887 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29888 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29889 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29914 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29915 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29916 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
29999 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
30400 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30410 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
0425U |
|
Diagnostic Services: Genetic Testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0426U |
|
Diagnostic Services: Genetic Testing |
Lab/genetic testing |
|
Yes |
Yes |
|
30420 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30430 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30435 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30450 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30460 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30462 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30520 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
|
30620 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
|
31295 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018 |
Yes |
Yes |
|
31296 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018 |
Yes |
Yes |
|
31297 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018 |
Yes |
Yes |
|
31298 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
|
31574 |
|
Reconstructive |
Injection procedure |
|
Yes |
Yes |
|
31591 |
|
Investigational and experimental procedures |
Reconstructive or cosmetic services |
|
Yes |
Yes |
|
31660 |
|
Surgery for select procedures |
Surgery - Lung |
|
Yes |
Yes |
|
31661 |
|
Surgery for select procedures |
Surgery - Lung |
|
Yes |
Yes |
|
32664 |
|
Surgery for select procedures |
surgery-musculoskeletal |
|
Yes |
Yes |
|
32850 |
|
Transplant surgeries |
Organ/Tissue transplant - Lung |
|
Yes |
Yes |
|
32851 |
|
Transplant surgeries |
Organ/Tissue transplant - Lung |
|
Yes |
Yes |
|
32852 |
|
Transplant surgeries |
Organ/Tissue transplant - Lung |
|
Yes |
Yes |
|
32853 |
|
Transplant surgeries |
Organ/Tissue transplant - Lung |
|
Yes |
Yes |
|
32854 |
|
Transplant surgeries |
Organ/Tissue transplant - Lung |
|
Yes |
Yes |
|
32855 |
|
Transplant surgeries |
Organ/Tissue transplant - Lung |
|
Yes |
Yes |
|
32856 |
|
Transplant surgeries |
Organ/Tissue transplant - Lung |
|
Yes |
Yes |
|
32998 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
|
33202 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33203 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33206 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33207 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33208 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33210 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33211 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33212 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33213 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33214 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33221 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33224 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33225 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33227 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33228 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33229 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33230 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33231 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33233 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33236 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33237 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33240 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33241 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33243 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33244 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33249 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33262 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33263 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33264 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33270 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33271 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33274 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33275 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33285 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33286 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33340 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33361 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33362 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33363 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33364 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33365 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33366 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33367 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33368 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33369 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33405 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33406 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33410 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33411 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33412 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33413 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33418 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33419 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33430 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33440 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33465 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33475 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33477 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33510 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33511 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33512 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33513 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33514 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33516 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33517 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33518 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33519 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33521 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33522 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33523 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33530 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33533 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33534 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33535 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33536 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33572 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
33927 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
|
33928 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
|
33930 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart/Lung |
|
Yes |
Yes |
|
33933 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart/Lung |
|
Yes |
Yes |
|
33935 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart/Lung |
|
Yes |
Yes |
|
33940 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
|
33944 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
|
33945 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
|
33975 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
33976 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
33977 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
33978 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
33979 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
No |
|
33980 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
No |
|
33981 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
33982 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
33983 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34701 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34702 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34703 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34704 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34705 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34706 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34707 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
34708 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
|
35302 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35303 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35304 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35305 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35371 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35372 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35556 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35558 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35566 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35571 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35583 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35585 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35587 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35656 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35661 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35666 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35671 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35700 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35881 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35883 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
35884 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
36465 |
|
Reconstructive or cosmetic services: Varicose veins |
Varicose vein procedure |
|
Yes |
No |
|
36466 |
|
Reconstructive or cosmetic services: Varicose veins |
Varicose vein procedure |
|
Yes |
No |
|
36468 |
|
Reconstructive or cosmetic services: Varicose veins |
Vein procedures |
|
Yes |
No |
|
36470 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
36471 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
36475 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
36478 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
36482 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
No |
|
37220 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37221 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37224 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37225 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37226 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37227 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37228 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37229 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37230 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37231 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37232 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37233 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37234 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37235 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37236 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37237 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37238 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37239 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37246 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37247 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37248 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37249 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
37500 |
|
Reconstructive or cosmetic services: Varicose veins |
Vein procedures |
|
Yes |
No |
|
37700 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37718 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37722 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37735 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37760 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37761 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37765 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37766 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37780 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
37785 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
No |
|
38205 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
|
38206 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
|
38207 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38208 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38209 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38210 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38211 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38212 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38213 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38214 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38215 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38230 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
|
38232 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
|
38240 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38241 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
|
38242 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
|
38243 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
|
4110F |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
43229 |
|
Outpatient surgery for select procedures |
Gastrointestinal procedure |
Requires preauthorization only for treatment of Barrett’s esophagus with dysplasia |
Yes |
No |
|
43270 |
|
Outpatient surgery for select procedures |
Gastrointestinal procedure |
Requires preauthorization only for treatment of Barrett’s esophagus with dysplasia |
Yes |
No |
|
43644 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43645 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43647 |
|
Outpatient services: bariatric surgery |
Surgery – Weight loss |
|
Yes |
Yes |
|
43648 |
|
Outpatient services: bariatric surgery |
Surgery – Weight loss |
|
Yes |
Yes |
|
43659 |
|
Outpatient surgery for select procedures |
Surgery - Stomach and intestines |
|
Yes |
No |
|
43770 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43771 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43772 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43773 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43774 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43775 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43842 |
|
Investigational and experimental procedures |
Investigational Weight Loss Surgery |
|
Yes |
No |
|
43843 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43845 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43846 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43847 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43848 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43881 |
|
Outpatient services: Bariatric surgery |
Surgery – Weight loss |
|
Yes |
Yes |
|
43882 |
|
Outpatient services: Bariatric surgery |
Surgery – Weight loss |
|
Yes |
Yes |
|
43886 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43887 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
43888 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
|
44132 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
No |
|
44133 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
No |
|
44135 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
No |
|
44136 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
No |
|
44715 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
Yes |
|
44720 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
Yes |
|
44721 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
Yes |
|
47133 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
Yes |
|
47135 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47140 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47141 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47142 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47143 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47144 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47145 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47146 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47147 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
|
47370 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
|
47380 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
|
47382 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
|
48160 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
No |
|
48550 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
|
48551 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
|
48552 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
|
48554 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
No |
|
48556 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
|
50300 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50320 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50323 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50325 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50327 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50328 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50329 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50340 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50360 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50365 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50380 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50547 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
|
50592 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
|
52441 |
|
Investigational and experimental procedures |
Investigational bladder procedure |
|
Yes |
Yes |
|
52442 |
|
Investigational and experimental procedures |
Investigational bladder procedure |
|
Yes |
Yes |
|
60660 |
|
Outpatient surgery for select procedures |
Surgery - Head/Face |
|
Yes |
No |
|
60661 |
|
Outpatient surgery for select procedures |
Surgery - Head/Face |
|
Yes |
No |
|
61863 |
|
Outpatient surgery for select procedures |
Surgery - Head/Face |
|
Yes |
Yes |
|
61867 |
|
Outpatient surgery for select procedures |
Surgery - Head/Face |
|
Yes |
Yes |
|
61880 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
61885 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
61886 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
61888 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
61889 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
|
61891 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
|
61892 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
|
62287 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63001 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63003 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63005 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63011 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63012 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63015 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63016 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63017 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63020 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63030 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63035 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63040 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63042 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63043 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63044 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63045 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63046 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63047 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63048 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63050 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63051 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63052 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63053 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63055 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63056 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63057 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63064 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63066 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63075 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63076 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63077 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63078 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63081 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63082 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63085 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63086 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63087 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63088 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63090 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63091 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63101 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63102 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63103 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63170 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63172 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63173 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63185 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63190 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63191 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63194 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63195 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63196 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63197 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63198 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63199 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63200 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63250 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63251 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63252 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63265 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63266 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63267 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63268 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63270 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63271 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63272 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63273 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63275 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63276 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63277 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63278 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63280 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63281 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63282 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63283 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63285 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63286 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63287 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63290 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63295 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63300 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63301 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63302 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63303 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63304 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63305 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63306 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63307 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63308 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
63650 |
|
Nerve stimulators and devices |
Nerve stimulator |
|
Yes |
No |
|
63655 |
|
Nerve stimulators and devices |
Nerve stimulator |
|
Yes |
No |
|
63685 |
|
Nerve stimulators and devices |
Nerve stimulator |
|
Yes |
No |
|
64553 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64561 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64566 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64568 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64569 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64570 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64580 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64581 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64582 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
|
64583 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
|
64596 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64598 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
|
64633 |
|
Investigational and experimental procedures |
Investigational Nerve Procedure |
|
Yes |
No |
|
64635 |
|
Outpatient surgery for select procedures |
Nerve Procedures |
|
Yes |
No |
|
65756 |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
No |
Yes |
|
65781 |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
Yes |
Yes |
|
65782 |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
Yes |
Yes |
|
65785 |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
Yes |
Yes |
|
66179 |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
Yes |
Yes |
|
66180 |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
Yes |
Yes |
|
66183 |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
Yes |
Yes |
|
66184 |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
Yes |
|
66989 |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
No |
|
66991 |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
No |
|
67900 |
|
Reconstructive or cosmetic services: Ptosis repair |
Surgery - Eyelid |
|
Yes |
No |
|
67901 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
67902 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
67903 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
67904 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
67906 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
67908 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
|
67909 |
|
Reconstructive or cosmetic services: Ptosis repair |
Surgery - Eyelid |
|
Yes |
No |
|
67911 |
|
Reconstructive or cosmetic services: Ptosis repair |
Surgery - Eyelid |
|
Yes |
No |
|
69300 |
|
Reconstructive or cosmetic services: Otoplasty |
Surgery - Head/Face |
|
Yes |
Yes |
|
69676 |
|
Surgery for select procedures |
Surgery - Head/Face |
|
Yes |
Yes |
|
69710 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
|
69711 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
|
69714 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
|
69716 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
|
69717 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
|
69719 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
|
69729 |
|
Dme: implantable device |
Hearing testing and treatment |
|
Yes |
Yes |
|
69730 |
|
Surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
|
69930 |
|
Surgery for select procedures |
Hearing testing and treatment |
|
Yes |
No |
|
70336 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70450 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70460 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70470 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70480 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70481 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70482 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70486 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70487 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70488 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70490 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70491 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70492 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70496 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70498 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70540 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70542 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70543 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70544 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70545 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70546 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. /p> |
Yes |
Yes |
|
70547 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70548 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70549 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70551 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70552 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70553 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70554 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
70555 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71250 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71260 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71270 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71271 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
No |
|
71275 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71550 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71551 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71552 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
71555 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72125 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72126 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72127 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72128 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72129 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72130 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72131 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72132 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72133 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72141 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72142 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72146 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72147 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72148 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. /p> |
Yes |
Yes |
|
72149 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72156 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72157 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72158 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72159 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72191 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72192 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72193 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72194 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72195 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72196 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72197 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
72198 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73200 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73201 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73202 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73206 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73218 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73219 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73220 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73221 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73222 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73223 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73225 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73700 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73701 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73702 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73706 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73718 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73719 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73720 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73721 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73722 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73723 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
73725 |
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74150 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74160 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74170 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74174 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74175 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74176 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74177 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74178 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74181 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74182 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74183 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74185 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74261 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74262 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74263 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
No |
|
74712 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
74713 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75557 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75559 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75561 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75563 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75565 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75571 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75572 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75573 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75635 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
75710 |
|
Diagnostic services: Diagnostic imaging |
Vascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
75716 |
|
Diagnostic services: Diagnostic imaging |
Vascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
75736 |
|
Diagnostic services: Diagnostic imaging |
Vascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
75820 |
|
Diagnostic services: Diagnostic imaging |
Vascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
75822 |
|
Diagnostic services: Diagnostic imaging |
Vascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
76380 |
|
Diagnostic services: CT scans |
X-ray/Imaging - cat scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
76390 |
|
Diagnostic services: SPECT |
Nuclear medicine testing - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77014 |
|
Therapy services: Radiation therapy , IGRT |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77046 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77047 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77048 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77049 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77084 |
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77280 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77285 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77290 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77295 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77300 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77301 |
|
Reconstructive or cosmetic services: Breast procedures |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77306 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77307 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77316 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77317 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77318 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77321 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77331 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77332 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77333 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77334 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77336 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77338 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77370 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77371 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77372 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77373 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77385 |
|
Therapy services: Radiation therapy , IMRT |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77386 |
|
Therapy services: Radiation therapy , IMRT |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77387 |
|
Therapy services: Radiation therapy , IGRT |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77399 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77401 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77402 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77407 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77412 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77417 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77423 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77424 |
|
Therapy services: Radiation therapy ,IORT |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77425 |
|
Therapy services: Radiation therapy ,IORT |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77427 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77431 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77432 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77435 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77469 |
|
Therapy services: Radiation therapy ,IORT |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77470 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77499 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77520 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77522 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77523 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77525 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77600 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77605 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77610 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77615 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77620 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77761 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77762 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77763 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77767 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77768 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77770 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77771 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77772 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77778 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77789 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77790 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
77799 |
|
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78429 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78430 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78431 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78432 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78433 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78434 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78445 |
|
Diagnostic services: Nuclear medicine |
Cardiovascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
78451 |
|
Diagnostic services: SPECT |
X-Ray/Imaging -SPECT |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78452 |
|
Diagnostic services: SPECT |
X-Ray/Imaging -SPECT |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78453 |
|
Diagnostic services: Cardiac Nuclear Medicine Studies |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78454 |
|
Diagnostic services: Cardiac Nuclear Medicine Studies |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78457 |
|
Diagnostic services: Nuclear medicine |
Cardiovascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
78458 |
|
Diagnostic services: Nuclear medicine |
Cardiovascular imaging study |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
78459 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78466 |
|
Diagnostic services: Cardiac Nuclear Medicine Studies |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78468 |
|
Diagnostic services: Cardiac Nuclear Medicine Studies |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78469 |
|
Outpatient surgery: Elective cardiac procedures |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78472 |
|
Diagnostic services: MUGA |
Nuclear medicine testing - heart |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78473 |
|
Diagnostic services: MUGA |
Nuclear medicine testing - heart |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78481 |
|
Outpatient surgery: Elective cardiac procedures |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78483 |
|
Outpatient surgery: Elective cardiac procedures |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78491 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78492 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78494 |
|
Diagnostic services: MUGA |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78496 |
|
Diagnostic services: MUGA |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78499 |
|
Diagnostic services: Cardiac Nuclear Medicine Studies |
X-Ray/Imaging - Heart studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78608 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78609 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78803 |
|
Diagnostic services: spect |
X-Ray/Imaging -SPECT
|
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78811 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78812 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78813 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78814 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78815 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78816 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78830 |
|
diagnostic services: spect |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78831 |
|
diagnostic services: spect |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
78832 |
|
diagnostic services: spect |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
81105 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81106 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81107 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81108 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81109 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81110 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81111 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81112 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81120 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81121 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81161 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81162 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81163 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81164 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81165 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81166 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81167 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81168 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81170 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81173 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81174 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81175 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81176 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81177 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81178 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81179 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81180 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81181 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81182 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81183 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81184 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81185 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81186 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81187 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81188 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81189 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81190 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81191 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81192 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81193 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81194 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81200 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81201 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81202 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81203 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81204 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81205 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81206 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81207 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81208 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81209 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81210 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81212 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81215 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81216 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81217 |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
81218 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81221 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81222 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81223 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81224 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81226 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81227 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81228 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81229 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81232 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81233 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81234 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81235 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81236 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81237 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81238 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81239 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81240 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81241 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81242 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81243 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81244 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81245 |
Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; dna analysis or combined dna and rna analysis |
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81246 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81250 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81251 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81252 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81253 |
|
Diagnostic services: Genetic testingg |
Lab/Genetic testing |
|
Yes |
No |
|
81254 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81255 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81256 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81257 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81258 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81259 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81260 |
|
Lab/Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
|
81261 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81262 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81263 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81264 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81265 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81266 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81269 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81270 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81271 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81272 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81273 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81274 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81275 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81276 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81277 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81278 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81283 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81284 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81285 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81286 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81288 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81289 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81290 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81292 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81293 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81294 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81295 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81296 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81297 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81298 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81299 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81300 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81301 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81302 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81303 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81304 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81305 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81306 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81307 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81308 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81309 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81310 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81311 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
No |
|
81312 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81314 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81315 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81316 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81317 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81318 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81319 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81320 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81321 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81322 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81323 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81324 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81325 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81326 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81327 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
No |
|
81328 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81330 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81331 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81332 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81333 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81334 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81335 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81336 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81337 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81340 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81341 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81342 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81343 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81344 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81345 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81347 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81348 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81349 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81350 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81351 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81352 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81353 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81357 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81360 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81361 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81362 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81363 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81364 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81400 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81401 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81402 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81403 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81404 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81405 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81406 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81407 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81408 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81410 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81411 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81412 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81413 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
No |
|
81414 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
No |
|
81415 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81416 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81417 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81418 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
No |
Yes |
|
81419 |
|
Diagnostic Services: Genetic Testing c |
Lab/Genetic testing |
|
Yes |
Yes |
|
81425 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81426 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81427 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81430 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81431 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81432 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81434 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81435 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81437 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
No |
Yes |
|
81439 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
No |
|
81440 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81441 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81442 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81443 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81445 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81448 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81450 |
|
Diagnostic services: genetic testing |
lab/Genetic testing |
; |
Yes |
Yes |
|
81451 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
|
81455 |
|
Diagnostic services: genetic testing |
lab/Genetic testing |
|
Yes |
No |
|
81456 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
|
81457 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81458 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81459 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81460 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81462 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81463 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81464 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81465 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81470 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81471 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
|
81479 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81493 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
|
81500 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
No |
Yes |
|
81540 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
5/1/2016 effective for Preauth. |
Yes |
Yes |
|
81541 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Non covered for commercial product |
Yes |
Yes |
|
81542 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
81546 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
If test does not meet criteria in the policy, it would be invalid |
Yes |
No |
|
81552 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
85300 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
85301 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
85302 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
85303 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
85305 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
85306 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
85307 |
|
Diagnostic services: genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
86152 |
|
Investigational and experimental procedures |
Investigational lab test |
|
Yes |
Yes |
|
86153 |
|
Investigational and experimental procedures |
Investigational lab test |
|
Yes |
Yes |
|
88240 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
|
88249 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88261 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88263 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88271 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88272 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88273 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88274 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88275 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
88291 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
|
90281 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
90283 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
90284 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
90378 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
90587 |
|
Medical Injectables/Other Non-Injectable Drug |
Medical Specialty Drug |
|
Yes |
No |
|
90867 |
|
Select outpatient behavioral health services |
Investigational Nerve stimulator |
|
Yes |
Yes |
|
90868 |
|
Select outpatient behavioral health services |
Investigational Nerve stimulator |
|
Yes |
Yes |
|
90869 |
|
Select outpatient behavioral health services |
Investigational Nerve stimulator |
|
Yes |
Yes |
|
92920 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92921 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92924 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92925 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92928 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92929 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92933 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92934 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92937 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92938 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92943 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
92944 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93303 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93304 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93306 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93307 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93308 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93312 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93313 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93314 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93315 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93316 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93317 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93318 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93350 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93351 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93352 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
93451 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93452 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93453 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93454 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93455 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93456 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93457 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93458 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93459 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93460 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93461 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93462 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93565 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93566 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93567 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93568 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
93745 |
|
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
95805 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
|
95807 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
|
95808 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
|
95810 |
|
Other services: Sleep studies facility based |
Sleep studies |
Preauthorization is not required for pediatrics less than 18 years of age. |
Yes |
No |
|
95811 |
|
Other services: Sleep studies facility based |
Sleep studies |
Preauthorization is not required for pediatrics less than 18 years of age. |
Yes |
No |
|
95930 |
|
Investigational and experimental procedures |
Brain testing |
|
Yes |
No |
|
96920 |
> |
Outpatient surgery for select procedures |
Treatment of skin diseases |
|
Yes |
Yes |
|
96921 |
|
Outpatient surgery for select procedures |
Treatment of skin diseases |
|
Yes |
Yes |
|
96922 |
Outpatient surgery for select procedures |
Treatment of skin diseases |
|
Yes |
Yes |
|
|
97037 |
|
Other services: laser treatment |
Investigational laser therapy |
|
Yes |
No |
|
97151 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
97152 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
97153 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
97154 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
97155 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
97156 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
97157 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
97158 |
|
Select outpatient behavioral health services |
Applied behavior analysis (ABA) |
|
Yes |
No |
|
0552U |
Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease[1]causing locus, and when possible, targeted mutation analysis for known familial variant, reported as low-risk or high-risk for familial genetic disorder |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0553U |
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using dna genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial dna score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0554U |
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using dna genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial dna score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0555U |
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using dna genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, a mitochondrial dna score, and embryo quality control, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0560U |
Oncology (minimal residual disease [mrd]), genomic sequence analysis, cell-free dna, whole blood and tumor tissue, baseline assessment for design and construction of a personalized variant panel to evaluate current mrd and for comparison to subsequent mrd assessments |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0561u |
Oncology (minimal residual disease [mrd]), genomic sequence analysis, cell-free dna, whole blood, subsequent assessment with comparison to initial assessment to evaluate for mrd |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0562u |
Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single-nucleotide variants (snvs), insertions and deletions, copy-number amplifications, and translocations in human genomic circulating cell-free dna, plasma, reported as presence of actionable variants |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0565U |
Oncology (hepatocellular carcinoma), next-generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell[1]free dna, plasma, algorithm reported as cancer signal detected or not detected |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0566U |
Oncology (lung), qpcr[1]based analysis of 13 differentially methylated regions (ccdc181, hoxa7, lrrc8a, marchf11, mir129-2, ncor2, pantr1, prkcb, slc9a3, tbr1_2, trap1, vwc2, znf781), pleural fluid, algorithm reported as a qualitative result |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0566U |
Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions and characterized intronic variants, copy-number variants, duplications/deletions, mobile element insertions, runs of homozygosity, aneuploidy, and inversions, mitochondrial dna sequence and deletions, short tandem repeat genes, methylation status of selected regions, blood, saliva, amniocentesis, chorionic villus sample or tissue, identification and categorization of genetic variants |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0569U |
Oncology (solid tumor), next[1]generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor dna (ctdna), whole blood, algorithm reported as presence or absence of ctdna with tumor fraction, if appropriate |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0569U |
Oncology (solid tumor), next[1]generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor dna (ctdna), whole blood, algorithm reported as presence or absence of ctdna with tumor fraction, if appropriate |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0571U |
Oncology (solid tumor), dna (80 genes) and rna (10 genes), by next-generation sequencing, plasma, including single-nucleotide variants, insertions/deletions, copy-number alterations, microsatellite instability, and fusions, reported as clinically actionable variants |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0572U |
Oncology (prostate), high[1]throughput telomere length quantification by fish, whole blood, diagnostic algorithm reported as risk of prostate cancer |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
0561U |
Oncology (minimal residual disease [mrd]), genomic sequence analysis, cell-free dna, whole blood, subsequent assessment with comparison to initial assessment to evaluate for mrd |
Diagnostic services: genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
|
A0430 |
Ambulance service, conventional air services, transport, one way (fixed wing) |
Office surgical procedures |
Non emergency ambulance transport |
|
Yes |
Yes |
|
A0431 |
Ambulance service, conventional air services, transport, one way (rotary wing) |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
|
Yes |
Yes |
|
A0435 |
Fixed wing air mileage, per statute mile |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
|
Yes |
Yes |
|
A0436 |
Rotary wing air mileage, per statute mile |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
|
Yes |
Yes |
|
A4560 |
Neuromuscular electrical stimulator (NMES), disposable, replacement only |
Nerve stimulators & devices |
Nerve stimulators |
|
Yes |
Yes |
|
A4290 |
Sacral Nerve stimulation test lead, each |
Investigational and experimental procedures |
Nerve stimulator |
|
Yes |
Yes |
|
A6515 |
Gradient compression wrap with adjustable straps, full leg, each, custom |
DME: Compression devices |
DME Supplies |
|
Yes |
No |
|
A6516 |
Gradient compression wrap with adjustable straps, foot, each, custom |
DME: Compression devices |
DME Supplies |
|
Yes |
No |
|
A6517 |
Gradient compression wrap with adjustable straps, below knee, each, custom |
DME: Compression devices |
DME Supplies |
|
Yes |
No |
|
A6518 |
Gradient compression wrap with adjustable straps, arm, each, custom |
DME: Compression devices |
DME Supplies |
|
Yes |
No |
|
A6519 |
Gradient compression garment, not otherwise specified, for nighttime use, each |
DME: Compression devices |
DME Supplies |
|
Yes |
No |
|
A6611 |
Gradient compression wrap with adjustable straps, above knee, each, custom |
DME: Compression devices |
DME Supplies |
|
Yes |
No |
|
A9274 |
External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories |
Diabetic DME & supplies |
DME supplies |
|
Yes |
No |
|
A9278 |
Receiver (monitor); external, for use with interstitial continuous glucose monitoring system |
Diabetic DME & supplies |
Diabetic Supplies |
|
Yes |
No |
|
A9513 |
Lutetium LU 177, dotatate, therapeutic, 1 millicurie |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
A9607 |
Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 mci |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
B4149 |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4150 |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4152 |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4153 |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4154 |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4155 |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4157 |
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4158 |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4159 |
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4160 |
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4161 |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B4162 |
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
No |
|
B9002 |
Enteral nutrition infusion pump - any type |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
|
B9998 |
NOC for enteral supplies |
Other services: enteral feeding and supplies |
DME supplies |
|
Yes |
No |
|
C1605 |
Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1721 |
Cardioverter-Defibrillator, Dual Chamber (Implantable) |
Select diagnostic and surgical cardiology services |
Cardioverter-defibrillators |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1722 |
Cardioverter-Defibrillator, Single Chamber (Implantable) |
Select diagnostic and surgical cardiology services |
Cardioverter-defibrillators |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1737 |
Joint fusion and fixation device(s), sacroiliac and pelvis, including all system components (implantable) |
DME: Prosthetic appliances and implants |
Prosthetic devices |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1764 |
Event Recorder, Cardiac (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1767 |
Generator, neurostimulator (implantable), non-rechargeable |
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
|
C1772 |
Infusion pump, programmable (implantable) |
DME: implant |
DME pump |
|
Yes |
Yes |
|
C1777 |
Lead, Cardioverter-Defibrillator, Endocardial Single Coil (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1778 |
Lead, neurostimulator (implantable) |
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
|
C1779 |
Lead, Pacemaker, Transvenous Vdd Single Pass |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1783 |
Ocular implant, aqueous drainage assist device |
DME: prosthetic appliances and implants |
Prosthetic devices |
Facility code requires preauthorization |
Yes |
Yes |
|
C1785 |
Pacemaker, Dual Chamber, Rate-Responsive (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1786 |
Pacemaker, Single Chamber, Rate-Responsive (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1787 |
Patient programmer neurostimulator |
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
|
C1789 |
Prosthesis, breast (implantable) |
Reconstructive or cosmetic services - breast procedures |
Surgery - breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
C1820 |
Generator, neurostimulator (implantable), with rechargeable battery and charging system |
Investigational and experimental procedures |
Investigational and experimental procedures |
Facility code requires preauth |
Yes |
Yes |
|
C1821 |
Interspinous process distraction device (implantable) |
DME: prosthetic appliances and implants |
Prosthetic devices |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1822 |
Generator, neurostimulator (implantable), high frequency , with rechargeable battery and charging system |
Investigational and experimental procedures |
Investigational Procedure |
Facility code requires preauthorization |
Yes |
Yes |
|
C1839 |
Iris prosthesis |
DME: Prosthetic appliances and implants |
Eye procedure |
|
Yes |
No |
|
C1874 |
Stent, Coated/Covered, With Delivery System |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1875 |
Stent, Coated/Covered, Without Delivery System |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1876 |
Stent, Non-Coated/Non-Covered, With Delivery System |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1877 |
Stent, Non-Coated/Non-Covered, Without Delivery System |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1880 |
Vena Cava Filter |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1882 |
Cardioverter-Defibrillator, Other Than Single Or Dual Chamber (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1883 |
Adaptor/extension, pacing lead or neurostimulator lead (implantable)
|
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
|
C1891 |
Infusion pump, Nonprogrammable, permanent (implantable) |
DME: implant |
DME pump |
|
Yes |
Yes |
|
C1895 |
Lead, Cardioverter-Defibrillator, Endocardial Dual Coil (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1896 |
Lead, Cardioverter-Defibrillator, Other Than Endocardial Single Or Dual Coil (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1897 |
Lead, neurostimulator test kit (implantable) |
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
|
C1898 |
Lead, Pacemaker, Other Than Transvenous Vdd Single Pass |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1899 |
Lead, Pacemaker/Cardioverter-Defibrillator Combination (Implantable) |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C1900 |
Lead Left Ventricular Coronary Venous System |
Select diagnostic and surgical cardiology services |
Devices, implants, and systems |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C2616 |
Brachytherapy source, non-stranded, YTTRIUM-90, per source |
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C2617 |
Stent, Non-Coronary, Temporary, Without Delivery System |
Select diagnostic and surgical cardiology services |
Cardiovascular device |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C2619 |
Pacemaker, Dual Chamber, Non Rate-Responsive (Implantable) |
Select diagnostic and surgical cardiology services |
Cardiovascular device |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C2620 |
Pacemaker, Single Chamber, Non Rate-Responsive (Implantable) |
Select diagnostic and surgical cardiology services |
Cardiovascular device |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C2621 |
Pacemaker, Other Than Single Or Dual Chamber (Implantable) |
Select diagnostic and surgical cardiology services |
Cardiovascular device |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C2623 |
Catheter Trnslum Angplasty Drug-Coated Non-Laser |
Select diagnostic and surgical cardiology services |
Cardiovascular device |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C2625 |
Stent, Non-Coronary, Temporary, With Delivery System |
Select diagnostic and surgical cardiology services |
Cardiovascular device |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C2626 |
Infusion pump, Nonprogrammable, temporary (implantable) |
DME: implant |
DME pump |
Facility code requires preauthorization |
Yes |
Yes |
|
C7564 |
Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance with intravascular ultrasound (noncoronary vessel(s)) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C7562 |
Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed with intraprocedural coronary fractional flow reserve (FFR) with 3D functional mapping of color-coded FFR values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C8900 |
Magnetic Resonance Angiography with contrast, abdomen |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8901 |
Magnetic Resonance Angiography without contrast, abdomen |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8902 |
Magnetic Resonance Angiography without contrast followed by with contrast, abdomen
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8903 |
Magnetic Resonance imaging with contrast, breast; unilateral |
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8905 |
Magnetic Resonance imaging without contrast, breast; unilateral
|
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8906 |
Magnetic Resonance imaging with contrast, breast; bilateral |
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8908 |
Magnetic Resonance imaging without contrast followed by with contrast, breast; bilateral |
Diagnostic services: MRI |
X-Ray/Imaging - MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8909 |
Magnetic Resonance Angiography with contrast, Chest (excluding myocardium) |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8910 |
Magnetic Resonance Angiography without contrast, Chest (excluding myocardium)
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8911 |
Magnetic Resonance Angiography without contrast followed by with contrast, Chest (excluding myocardium) |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8912 |
Magnetic Resonance Angiography with contrast, lower extremity |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8913 |
Magnetic Resonance Angiography without contrast, lower extremity
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8914 |
Magnetic Resonance Angiography without contrast followed by with contrast, lower extremity
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8918 |
Magnetic Resonance Angiography with contrast, pelvis
|
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8919 |
Magnetic Resonance Angiography without contrast, pelvis |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8920 |
Magnetic Resonance Angiography without contrast followed by with contrast, pelvis |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8921 |
Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8922 |
Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8923 |
Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, complete, without SPECTRAL or color doppler echocardiography |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8924 |
Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording when performed, follow-up or limited study |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8925 |
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without m-mode recording); including probe placement, image acquisition, interpretation and report |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8926 |
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8927 |
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for monitoring purposes, including probe placement, real time (2D) image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8928 |
Transthoracic echocardiography (TTE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8929 |
Transthoracic echocardiography (TTE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8930 |
Transthoracic echocardiography (TTE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8931 |
Magnetic Resonance Angiography with contrast, spinal canal and contents |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8932 |
Magnetic resonance angiography without contrast, spinal canal and contents |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8933 |
Magnetic Resonance Angiography without contrast followed by with contrast, spinal canal and contents |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8934 |
Magnetic Resonance Angiography with contrast, upper extremity |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8935 |
Magnetic Resonance Angiography without contrast, upper extremity |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C8936 |
Magnetic Resonance Angiography without contrast followed by with contrast, upper extremity |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
C9069 |
Injection, belantamab mafodotin-blmf |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. preauthorization only for this specialty injectable |
Yes |
No |
|
C9070 |
Injection, tafasitamab-cxix, 2 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
|
Yes |
No |
|
C9072 |
Injection immune globulin (asceniv), 500mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
|
Yes |
No |
|
C9073 |
Brexucabtagene autoleucel, up to 200 million autologous anti-cd 19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose tacaretus |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
|
Yes |
No |
|
C9171 |
Injection, fidanacogene eleparvovec-dzkt, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
C9174 |
Injection, datopotamab deruxtecan-dlnk, 1 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
C9600 |
Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9601 |
Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9602 |
Percutaneous Transluminal Coronary Atherectomy, With Drug Eluting Intracoronary Stent, With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9603 |
Percutaneous Transluminal Coronary Atherectomy, With Drug-Eluting Intracoronary Stent, With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9604 |
Percutaneous Transluminal Revascularization Of Or Through Coronary Artery Bypass Graft (Internal Mammary, Free Arterial, Venous), Any Combination Of Drug-Eluting Intracoronary Stent, Atherectomy And Angioplasty, Including Distal Protection When Performed; Single Vessel |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9605 |
Percutaneous Transluminal Revascularization Of Or Through Coronary Artery Bypass Graft (Internal Mammary, Free Arterial, Venous), Any Combination Of Drug-Eluting Intracoronary Stent, Atherectomy And Angioplasty, Including Distal Protection When Performed; Each Additional Branch Subtended By The Bypass Graft (List Separately In Addition To Code For Primary Procedure) |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9606 |
Percutaneous Transluminal Revascularization Of Acute Total/Subtotal Occlusion During Acute Myocardial Infarction, Coronary Artery Or Coronary Artery Bypass Graft, Any Combination Of Drug-Eluting Intracoronary Stent, Atherectomy And Angioplasty, Including Aspiration Thrombectomy When Performed, Single Vessel |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9607 |
Percutaneous Transluminal Revascularization Of Chronic Total Occlusion, Coronary Artery, Coronary Artery Branch, Or Coronary Artery Bypass Graft, Any Combination Of Drug-Eluting Intracoronary Stent, Atherectomy And Angioplasty; Single Vessel |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9608 |
Percutaneous Transluminal Revascularization Of Chronic Total Occlusion, Coronary Artery, Coronary Artery Branch, Or Coronary Artery Bypass Graft, Any Combination Of Drug-Eluting Intracoronary Stent, Atherectomy And Angioplasty; Each Additional Coronary Artery, Coronary Artery Branch, Or Bypass Graft (List Separately In Addition To Code For Primary Procedure) |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9610 |
Catheter, transluminal drug delivery with or without angioplasty, coronary, nonlaser (insertable) |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9739 |
Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants |
Investigational and experimental procedures |
Investigational bladder procedure |
|
Yes |
Yes |
|
C9740 |
Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants |
Investigational and experimental procedures |
Investigational bladder procedure |
|
Yes |
Yes |
|
C9757 |
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar |
Surgery for select procedures |
Nerve Procedures |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
C9763 |
Cardiac Magnetic Resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging |
Diagnostic services: MRI |
Diagnostic services : MRI |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
D7820 |
Closed reduction of dislocation; joint manipulated into place; no surgical exposure |
Office surgical procedures |
Dental procedures |
Requires preauthorization only performed in a facility. |
Yes |
No |
|
D7870 |
Arthrocentesis; withdrawal of fluid from a joint space by aspiration |
Office surgical procedures |
Dental procedures |
Requires preauthorization only performed in a facility. |
Yes |
No |
|
D7880 |
Occlusal orthotic device, by report; presently includes splints provided for treatment of temporomandibular joint dysfunction. |
Office surgical procedures |
Dental procedures |
Requires preauthorization only when performed in a facility. |
Yes |
No |
|
E0183 |
Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty |
DME: hospital beds & supplies |
DME supplies |
|
Yes |
No |
|
E0193 |
Powered air flotation bed (low air Loss therapy ) |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0194 |
Air fluidized bed |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0250 |
Hospital bed, fixed height, with any type side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0251 |
Hospital bed, fixed height, with any type side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0255 |
Hospital bed, variable height, HI-LO, with any type side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0256 |
Hospital bed, variable height, HI-LO, with any type side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0261 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0265 |
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0266 |
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0270 |
Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
Yes |
|
E0277 |
Powered pressure-reducing air mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0290 |
Hospital bed, fixed height, without side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0291 |
Hospital bed, fixed height, without side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0292 |
Hospital bed, variable height, HI-LO, without side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0293 |
Hospital bed, variable height, HI-LO, without side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0294 |
Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0295 |
Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0296 |
Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0297 |
Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0300 |
Pediatric crib, hospital grade, fully enclosed, with or without top enclosure |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
Yes |
|
E0301 |
Hospital bed, heavy-duty, extra wide, with Weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0302 |
Hospital bed, extra heavy-duty, extra wide, with Weight capacity greater than 600 pounds, with any type side rails, without mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0303 |
Hospital bed, heavy-duty, extra wide, with Weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0304 |
Hospital bed, extra heavy-duty, extra wide, with Weight capacity greater than 600 pounds, with any type side rails, with mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0328 |
Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0329 |
Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
No |
|
E0462 |
Rocking bed, with or without side rails |
DME: hospital beds & supplies |
Hospital bed |
|
Yes |
Yes |
|
E0465 |
Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) |
DME: ventilators & airway assist devices |
DME device |
|
Yes |
Yes |
|
E0466 |
Home ventilator, any type, used with Noninvasive interface, (e.g., mask, Chest shell) |
DME: ventilators & airway assist devices |
DME device |
|
Yes |
Yes |
|
E0467 |
Home ventilator, multi-function Respiratory device, also performs any or all of the additional functions of Oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions |
DME: ventilators & airway assist devices |
DME device |
|
Yes |
Yes |
|
E0468 |
Home ventilator, dual-function respiratory device, also performs newitional function of cough stimulation, includes all accessories, components and supplies for all functions |
DME: ventilators & airway assist devices |
DME device |
|
Yes |
No |
|
E0470 |
Respiratory assist device, bi-level pressure capability, without backup rate feature, used with Noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
DME: ventilators & airway assist devices |
DME: C-PAP & supplies |
|
Yes |
Yes |
|
E0471 |
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with Noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
DME: ventilators & airway assist devices |
DME: C-PAP & supplies |
|
Yes |
Yes |
|
E0472 |
Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device |
DME: ventilators & airway assist devices |
DME: C-PAP & supplies |
|
Yes |
Yes |
|
E0481 |
Intrapulmonary percussive ventilation system and related accessories |
DME: ventilators & airway assist devices |
DME device |
|
Yes |
No |
|
E0482 |
Cough stimulating device, alternating positive and negative airway pressure |
DME: ventilators & airway assist devices |
DME device |
|
Yes |
Yes |
|
E0483 |
High frequency Chest Wall Oscillation air-pulse generator system, (includes hoses and vest), each |
DME: ventilators & airway assist devices |
DME device |
|
Yes |
Yes |
|
E0486 |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or Nonadjustable, custom fabricated, includes fitting and adjustment |
DME: equipment |
DME supplies |
|
Yes |
Yes |
|
E0561 |
Humidifier, Non-heated, used with positive airway pressure device |
DME: ventilators & airway assist devices |
DME: C-PAP & supplies |
|
Yes |
No |
|
E0616 |
Implantable Cardiac Event Recorder With Memory, Activator And Programmer |
DME: Monitoring equipment |
DME: Monitoring equipment |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
E0636 |
Multi-positional patient support system, with integrated lift, patient accessible controls |
DME: patient lifts |
DME supplies |
|
Yes |
Yes |
|
E0673 |
Segmental gradient pressure pneumatic appliance, half leg |
DME: compression devices |
DME supplies |
|
Yes |
Yes |
|
E0676 |
Intermittent limb compression device (includes all accessories), not otherwise specified |
DME: compression devices |
DME supplies |
|
Yes |
No |
|
E0683 |
Non-pneumatic, non-sequential, peristaltic wave compression pump |
DME: compression devices |
DME supplies |
|
Yes |
No |
|
E0694 |
Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection |
DME: equipment |
DME supplies |
|
Yes |
Yes |
|
E0737 |
Transcutaneous tibial nerve stimulator, controlled by phone application |
Nerve Stimulators & devices |
Nerve Stimulator |
|
Yes |
No |
|
E0745 |
Neuromuscular Stimulator, electronic shock unit |
Nerve stimulators and devices |
Nerve stimulator |
|
Yes |
Yes |
|
E0747 |
Osteogenesis Stimulator, electrical, Noninvasive, other than spinal applications |
Nerve stimulators and devices |
Nerve stimulator |
|
Yes |
Yes |
|
E0748 |
Osteogenesis Stimulator, electrical, Noninvasive, spinal applications |
Nerve stimulators and devices |
Nerve stimulator |
|
Yes |
Yes |
|
E0764 |
Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program |
Nerve stimulators and devices |
Nerve stimulator |
|
Yes |
Yes |
|
E0766 |
Electrical stimulation device used for cancer treatment, includes all accessories, any type |
DME: prosthetic appliances and implants |
Nerve stimulator |
|
Yes |
Yes |
|
E0782 |
Infusion pump, implantable, Nonprogrammable (includes all components, e.g., pump, catheter, connectors, etc.) |
DME: implant |
DME pump |
|
Yes |
Yes |
|
E0783 |
Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.) |
DME: implant |
DME pump |
|
Yes |
Yes |
|
E0784 |
External ambulatory infusion pump, insulin |
Diabetic DME & supplies |
Diabetic Supplies |
|
Yes |
Yes |
|
E0785 |
Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement |
DME: implant |
DME pump |
|
Yes |
Yes |
|
E0786 |
Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) |
DME: implant |
DME pump |
|
Yes |
Yes |
|
E0787 |
External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing |
DME: equipment |
DME supplies |
|
Yes |
Yes |
|
E0935 |
Continuous passive motion exercise device for use on knee only |
DME: equipment |
DME supplies |
|
Yes |
Yes |
|
E0951 |
Heel loop/holder, any type, with or without ankle strap, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0952 |
Toe loop/holder, any type, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0953 |
Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0954 |
Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0955 |
Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0956 |
Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0957 |
Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0958 |
Manual wheelchair accessory, one-arm drive attachment, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0959 |
Manual wheelchair accessory, adapter for amputee, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0960 |
Wheelchair accessory, shoulder harness/straps or Chest strap, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0961 |
Manual wheelchair accessory, wheel lock brake extension (handle), each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0966 |
Manual wheelchair accessory, headrest extension, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0967 |
Manual wheelchair accessory, hand rim with projections, any type, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0968 |
Commode seat, wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E0969 |
Narrowing device, wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E0970 |
No. 2 footplates, except for elevating leg rest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E0971 |
Manual wheelchair accessory, anti-tipping device, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0973 |
Wheelchair accessory, adjustable height, Detachable armrest, complete assembly, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0974 |
Manual wheelchair accessory, anti-rollback device, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0978 |
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0980 |
Safety vest, wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E0981 |
Wheelchair accessory, seat upholstery, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0982 |
Wheelchair accessory, back upholstery, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0988 |
Manual wheelchair accessory, lever-activated, wheel drive, pair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0990 |
Wheelchair accessory, elevating leg rest, complete assembly, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0992 |
Manual wheelchair accessory, solid seat insert |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E0994 |
Armrest, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E0995 |
Wheelchair accessory, calf rest/pad, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1002 |
Wheelchair accessory, power seating system, tilt only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1003 |
Wheelchair accessory, power seating system, recline only, without shear reduction |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1004 |
Wheelchair accessory, power seating system, recline only, with mechanical shear reduction |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1005 |
Wheelchair accessory, power seating system, recline only, with power shear reduction |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1006 |
Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1007 |
Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1008 |
Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1009 |
Wheelchair accessory, addition to power seating system, power leg elevation system, including legrest, pair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1010 |
Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1011 |
Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1012 |
Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1014 |
Reclining back, addition to pediatric size wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1016 |
Shock absorber for power wheelchair, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1017 |
Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1018 |
Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1020 |
Residual limb support system for wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1028 |
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1029 |
Wheelchair accessory, ventilator tray, fixed |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1030 |
Wheelchair accessory, ventilator tray, gimbaled |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1032 |
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1033 |
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1034 |
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1035 |
Multi-positional patient transfer system, with integrated seat, operated by care giver, patient Weight capacity up to and including 300 lbs |
DME: patient lifts |
DME supplies |
|
Yes |
Yes |
|
E1036 |
Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient Weight capacity greater than 300 lbs |
DME: patient lifts |
DME supplies |
|
Yes |
Yes |
|
E1037 |
Transport chair, pediatric size |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1038 |
Transport chair, adult size, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1039 |
Transport chair, adult size, heavy-duty, patient Weight capacity greater than 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1050 |
Fully reclining wheelchair; fixed full-length arms, swing-away, Detachable, elevating leg rests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1060 |
Fully-reclining wheelchair, Detachable arms, desk or full-length, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1070 |
Fully-reclining wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1083 |
Hemi-wheelchair; fixed full-length arms, swing-away, Detachable, elevating leg rests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1084 |
Hemi-wheelchair, Detachable arms desk or full-length arms, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1085 |
Hemi-wheelchair, fixed full-length arms, swing-away Detachable footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1086 |
Hemi-wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1087 |
High strength lightweight wheelchair, fixed full-length arms, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1088 |
High strength lightweight wheelchair, Detachable arms desk or full-length, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1089 |
High-strength lightweight wheelchair, fixed-length arms, swing-away Detachable footrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1090 |
High-strength lightweight wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1092 |
Wide heavy-duty wheel chair, Detachable arms (desk or full-length), swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1093 |
Wide heavy-duty wheelchair, Detachable arms, desk or full-length arms, swing-away Detachable footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1100 |
Semi-reclining wheelchair, fixed full-length arms, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1110 |
Semi-reclining wheelchair, Detachable arms (desk or full-length) elevating legrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1130 |
Standard wheelchair, fixed full-length arms, fixed or swing-away Detachable footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1140 |
Wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1150 |
Wheelchair, Detachable arms, desk or full-length swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1160 |
Wheelchair, fixed full-length arms, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1161 |
Manual adult size wheelchair, includes tilt in space |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1170 |
Amputee wheelchair, fixed full-length arms, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1171 |
Amputee wheelchair, fixed full-length arms, without footrests or legrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1172 |
Amputee wheelchair, Detachable arms (desk or full-length) without footrests or legrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1180 |
Amputee wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1190 |
Amputee wheelchair, Detachable arms (desk or full-length) swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1195 |
Heavy-duty wheelchair, fixed full-length arms, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1200 |
Amputee wheelchair, fixed full-length arms, swing-away Detachable footrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1220 |
Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1221 |
Wheelchair with fixed arm, footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1222 |
Wheelchair with fixed arm, elevating leg rests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1223 |
Wheelchair with Detachable arms, footrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1224 |
Wheelchair with Detachable arms, elevating leg rests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1225 |
Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1226 |
Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1227 |
Special height arms for wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1228 |
Special back height for wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1229 |
Wheelchair, pediatric size, not otherwise specified |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1230 |
Power operated Vehicle (3- or 4-wheel nonhighway), specify brand name and model number |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1231 |
Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1232 |
Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1233 |
Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1234 |
Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1235 |
Wheelchair, pediatric size, rigid, adjustable, with seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1236 |
Wheelchair, pediatric size, folding, adjustable, with seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1237 |
Wheelchair, pediatric size, rigid, adjustable, without seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1238 |
Wheelchair, pediatric size, folding, adjustable, without seating system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1239 |
Power wheelchair, pediatric size, not otherwise specified |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1240 |
Lightweight wheelchair, Detachable arms, (desk or full-length) swing-away Detachable, elevating legrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1250 |
Lightweight wheelchair, fixed full-length arms, swing-away Detachable footrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1260 |
Lightweight wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1270 |
Lightweight wheelchair, fixed full-length arms, swing-away Detachable elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1280 |
Heavy-duty wheelchair, Detachable arms (desk or full-length) elevating legrests |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1285 |
Heavy-duty wheelchair, fixed full-length arms, swing-away Detachable footrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1290 |
Heavy-duty wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1295 |
Heavy-duty wheelchair, fixed full-length arms, elevating legrest |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E1296 |
Special wheelchair seat height from floor |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1297 |
Special wheelchair seat depth, by upholstery |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E1298 |
Special wheelchair seat depth and/or width, by construction |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2102 |
Adjunctive, non-implanted continuous glucose monitor or receiver |
Diabetic DME and supplies |
Diabetic supplies |
|
Yes |
No |
|
E2201 |
Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 in and less than 24 in |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2202 |
Manual wheelchair accessory, nonstandard seat frame width, 24-27 in |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2203 |
Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 in |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2204 |
Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 in |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2205 |
Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2206 |
Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2208 |
Wheelchair accessory, cylinder tank carrier, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2209 |
Accessory, arm trough, with or without hand support, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2210 |
Wheelchair accessory, bearings, any type, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2211 |
Manual wheelchair accessory, pneumatic propulsion tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2212 |
Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2214 |
Manual wheelchair accessory, pneumatic caster tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2215 |
Manual wheelchair accessory, tube for pneumatic caster tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2216 |
Manual wheelchair accessory, foam filled propulsion tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2217 |
Manual wheelchair accessory, foam filled caster tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2218 |
Manual wheelchair accessory, foam propulsion tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2219 |
Manual wheelchair accessory, foam caster tire, any size, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2220 |
Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2221 |
Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2222 |
Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2224 |
Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2225 |
Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2226 |
Manual wheelchair accessory, caster fork, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2227 |
Manual wheelchair accessory, gear reduction drive wheel, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2228 |
Manual wheelchair accessory, wheel braking system and lock, complete, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2230 |
Manual wheelchair accessory, manual standing system |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2231 |
Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2291 |
Back, planar, for pediatric size wheelchair including fixed attaching hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2292 |
Seat, planar, for pediatric size wheelchair including fixed attaching hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2293 |
Back, contoured, for pediatric size wheelchair including fixed attaching hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2294 |
Seat, contoured, for pediatric size wheelchair including fixed attaching hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2298 |
Complex rehabilitative power wheelchair accessory, power seat elevation system, any type |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2310 |
Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2311 |
Power wheelchair accessory, electronic connection between wheelchair controller and 2 or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2312 |
Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2313 |
Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2321 |
Power wheelchair accessory, hand control interface, remote joystick, Nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2322 |
Power wheelchair accessory, hand control interface, multiple mechanical switches, Nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2323 |
Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2324 |
Power wheelchair accessory, chin Cup for chin control interface |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2325 |
Power wheelchair accessory, SIP and PUFF interface, Nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2326 |
Power wheelchair accessory, breath tube kit for SIP and PUFF interface |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2327 |
Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2328 |
Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2329 |
Power wheelchair accessory, head control interface, contact switch mechanism, Nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2330 |
Power wheelchair accessory, head control interface, proximity switch mechanism, Nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2340 |
Power wheelchair accessory, nonstandard seat frame width, 20-23 inches |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2341 |
Power wheelchair accessory, nonstandard seat frame width, 24-27 inches |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2342 |
Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2343 |
Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2351 |
Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2359 |
Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2361 |
Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g. gel cell, absorbed glassmat) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2363 |
Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2365 |
Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2366 |
Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2367 |
Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
E2368 |
Power wheelchair component, motor, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2369 |
Power wheelchair component, gear box, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2370 |
Power wheelchair component, motor and gear box combination, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2371 |
Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2373 |
Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2374 |
Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2375 |
Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2376 |
Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2377 |
Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2378 |
Power wheelchair component, actuator, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2381 |
Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2382 |
Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2383 |
Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2384 |
Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2385 |
Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2386 |
Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2387 |
Power wheelchair accessory, foam filled caster tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2388 |
Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2389 |
Power wheelchair accessory, foam caster tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2390 |
Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2391 |
Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2392 |
Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2394 |
Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2395 |
Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2396 |
Power wheelchair accessory, caster fork, any size, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2397 |
Power wheelchair accessory, lithium-based battery, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2398 |
Wheelchair accessory, dynamic positioning hardware for back |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2402 |
Negative pressure wound therapy electrical pump, Stationary or Portable |
DME: equipment |
DME pump |
|
Yes |
Yes |
|
E2500 |
Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2502 |
Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2504 |
Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2506 |
Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2508 |
Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2510 |
Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2511 |
Speech generating software program, for personal computer or personal digital assistant |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2512 |
Accessory for speech generating device, mounting system |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2513 |
Accessory For Speech Generatng Device, Electromyographic Sensor |
Dme: Speech Generating Devices |
Speech devices |
|
Yes |
Yes |
|
E2599 |
Accessory for speech generating device, not otherwise classified |
Investigational and experimental procedures |
Speech devices |
|
Yes |
Yes |
|
E2601 |
General use wheelchair seat cushion, width less than 22 inches, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2602 |
General use wheelchair seat cushion, width 22 inches or greater, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2603 |
Skin protection wheelchair seat cushion, width less than 22 inches, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2604 |
Skin protection wheelchair seat cushion, width 22 inches or greater, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2605 |
Positioning wheelchair seat cushion, width less than 22 inches, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2606 |
Positioning wheelchair seat cushion, width 22 inches or greater, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2607 |
Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2608 |
Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2609 |
Custom fabricated wheelchair seat cushion, any size |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2611 |
General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2612 |
General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2613 |
Positioning wheelchair back cushion, posterior, width less than 22 in, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2614 |
Positioning wheelchair back cushion, posterior, width 22 in or greater, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2615 |
Positioning wheelchair back cushion, posterior-lateral, width less than 22 in, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2616 |
Positioning wheelchair back cushion, posterior-lateral, width 22 in or greater, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2617 |
Custom fabricated wheelchair back cushion, any size, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2619 |
Replacement cover for wheelchair seat cushion or back cushion, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2620 |
Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2621 |
Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2622 |
Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2623 |
Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2624 |
Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2625 |
Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2626 |
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2627 |
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2628 |
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2629 |
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2630 |
Wheelchair accessory, shoulder elbow, mobile arm support, mono suspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2631 |
Wheelchair accessory, addition to mobile arm support, elevating proximal arm |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2632 |
Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E2633 |
Wheelchair accessory, addition to mobile arm support, supinator |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
E3000 |
Speech volume modulation system, any type, including all components and accessories |
DME: Wheelchairs and accessories |
Speech devices |
|
Yes |
No |
|
G0151 |
Services performed by a qualified Physical therapist in the home health or hospice setting, each 15 minutes |
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
|
G0152 |
Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes |
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
|
G0155 |
Services of clinical Social worker in home health or hospice settings, each 15 minutes |
Other services: Home health care |
Home health care |
|
Yes |
Yes |
|
G0156 |
Services of home health/hospice aide in home health or hospice settings, each 15 minutes |
Other services: Home health care |
Home health care |
|
Yes |
Yes |
|
G0159 |
Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes |
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
No |
|
G0160 |
Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes |
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
No |
|
G0162 |
Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an rn to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting) |
Other services: Home health care |
Home health care |
|
No |
Yes |
|
G0219 |
PET imaging whole body; melanoma for non-covered indications |
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
G0235 |
Pet Imaging, any site, not otherwise specified |
Diagnostic services: pet scans |
Xray/imaging - pet scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
No |
|
G0252 |
PET imaging, full and partial-ring pet scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes) |
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
G0299 |
Direct skilled nursing services of A registered nurse (RN) in the home health or hospice setting, each 15 minutes |
Other services: Home health care |
Home health care |
|
Yes |
Yes |
|
G0300 |
Direct skilled nursing services of A license practical nurse (LPN) in the home health or hospice setting, each 15 minutes |
Other services: Home health care |
Home health care |
|
Yes |
Yes |
|
G0339 |
Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment |
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
G0340 |
Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment |
Therapy services: Radiation therapy |
Radiation therapy |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
Yes |
|
G0341 |
Percutaneous Islet cell Transplant, includes portal vein catheterization and infusion |
Transplant surgeries |
Organ/Tissue transplant - Islet cell (pancreas) |
|
Yes |
No |
|
G0342 |
Laparoscopy for Islet cell Transplant, includes portal vein catheterization and infusion |
Transplant surgeries |
Organ/Tissue transplant - Islet cell (pancreas) |
|
Yes |
No |
|
G0343 |
Laparotomy for Islet cell Transplant, includes portal vein catheterization and infusion |
Transplant surgeries |
Organ/Tissue transplant - Islet cell (pancreas) |
|
Yes |
No |
|
G0448 |
Insertion Or Replacement Of A Permanent Pacing Cardioverter-Defibrillator System With Transvenous Lead(S), Single Or Dual Chamber With Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
G0493 |
Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting) |
Home care |
Home health care |
|
Yes |
Yes |
|
G0494 |
Skilled services of A licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting) |
Home care |
Home health care |
|
Yes |
Yes |
|
H0015 |
Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education |
Select outpatient behavioral health services |
Behavioral health services |
Not valid for Medicare purposes. |
Yes |
No |
|
H0018 |
Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem |
Select outpatient behavioral health services |
Behavioral health services |
|
Yes |
No |
|
H0035 |
Mental health partial hospitalization, treatment, less than 24 hours |
Select outpatient behavioral health services |
Behavioral health services |
Not valid for Medicare purposes. |
Yes |
No |
|
J0129 |
Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0174 |
Injection, lecanemab-irmb, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0175 |
Injection, donanemab-azbt, 2 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J0177 |
Injection, aflibercept hd, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J0178 |
Injection, aflibercept, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0638 |
Injection, canakinumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J0641 |
Injection, levoleucovorin, not otherwise specified, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J0642 |
Injection, levoleucovorin (khapzory), 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J2267 |
Injection, mirikizumab-mrkz, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J3263 |
injection, toripalimab-tpzi, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J3391 |
Injection, atidarsagene autotemcel, per treatment |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J3393 |
Injection, betibeglogene autotemcel, per treatment |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3394 |
Injection lovotibeglogene autotemcel, per treatment |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2777 |
Injection, faricimab-svoa, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0179 |
Injection, brolucizumab-dbll, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0180 |
Injection, agalsidase beta, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0202 |
Injection, alemtuzumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0217 |
Injection, velmanase alfa-tycv, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J0218 |
Injection, olipudase alfa-rpcp, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0219 |
Injection, avalglucosidase alfa-ngpt, 4 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0221 |
Injection, alglucosidase alfa, (lumizyme), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0222 |
Injection, patisiran, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0223 |
Injection, givosiran, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0224 |
Injection, lumasiran, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0225 |
Injection, vutrisiran, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0256 |
Injection, alpha 1- proteinase inhibitor (human), not otherwise specified, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0257 |
Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0490 |
Injection, belimumab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0491 |
Injection, anifrolumab-fnia, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J0517 |
Injection, benralizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0567 |
Injection, cerliponase alfa, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J0584 |
Injection, burosumab-twza, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0585 |
Injection, onabotulinumtoxina, 1 unit |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0586 |
Injection, abobotulinumtoxina, 5 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0587 |
Injection, rimabotulinumtoxinB, 100 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J0588 |
Injection, incobotulinumtoxina, 1 unit |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0589 |
Injection, daxibotulinumtoxina-lanm, 1 unit |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthoirzed by Capital Blue Cross for Commercial. |
Yes |
No |
|
J0593 |
Injection, lanadelumab-flyo, 1mg (code may be used for medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered. |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J0596 |
Injection, C1 esterase inhibitor (recombinant), rucontest, 10 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J0597 |
Injection, C-1 esterase inhibitor (human), BERINERT, 10 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J0598 |
Injection, C-1 esterase inhibitor (human), CINRYZE, 10 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0717 |
Injection, certolizumab pegol, 1mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0791 |
Injection, crizanlizumab-tmca, 5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0870 |
Injection, imetelstat, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
J0881 |
Injection, darbepoetin alfa, 1 mcg (non-esrd use) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0885 |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0888 |
Injection, epoetin beta, 1 mcg, (for non-esrd use) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0896 |
Injection, luspatercept-aamt, 0.25 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J0897 |
Injection, denosumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1203 |
Injection, cipaglucosidase alfa-atga , 5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J1290 |
Injection, ecallantide, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
No |
|
J1299 |
Injection, eculizumab, 2mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1301 |
Injection, edaravone, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J1302 |
INJECTION, SUTIMLIMAB-JOME, 10mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1303 |
Injection, ravulizumab-cwvz, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J1304 |
Injection, tofersen, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1305 |
Injection evkeeza (evinacumab-dgnb), 5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1306 |
Injection, inclisiran, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J1307 |
Injection, crovalimab-akkz, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
J1322 |
Injection, elosulfase alfa, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1323 |
Injection, elranatamab-bcmm, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J1325 |
Injection, epoprostenol, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J1326 |
Injection, zolbetuximab-clzb, 2 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Bue Cross for commercial. . |
Yes |
No |
|
J1411 |
Injection, etranacogene dezaparvove-DRLB, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1412 |
Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes. |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1413 |
Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1414 |
Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1426 |
Injection, casimersen, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1427 |
Injection, viltolarsen, 10 mg |
Medical injectiables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1428 |
Injection, eteplirsen, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1429 |
Injection, golodirsen, 10mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1437 |
Injection, ferric derisomaltose, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J1439 |
Injection, ferric carboxymaltose, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J1442 |
Injection, filgrastim (G-CSF), excludes biosimilars, 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1447 |
Injection, TBO-filgrastim, 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J1448 |
Injection, trilaciclib (cosela) , 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J1449 |
Injection, eflapegrastim-XNST, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1458 |
Injection, galsulfase, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMedss. |
Yes |
Yes |
|
J1459 |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1460 |
Injection, gamma globulin, intramuscular, 1 CC |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J1551 |
Injection, immune globulin (cutaquig), 100 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for commercial. |
Yes |
No |
|
J1552 |
Injection, immune globulin (alyglo), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1555 |
Injection, immune globulin (cuvitru), 100 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1556 |
Injection, immune globulin (bivigam), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1557 |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1558 |
Injection, immune globulin (xembify), 100 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1559 |
Injection, immune globulin (hizentra), 100 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1560 |
Injection, gamma globulin, intramuscular, over 10 cc |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
No |
|
J1561 |
Injection, immune globulin, (gamunex- c/gammaked), non-lyophilized (E. G. liquid), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1566 |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1568 |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1569 |
Injection, immune globulin, (gammagard liquid), non-lyophilized, (E. G. liquid), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1572 |
Injection, immune globulin, (flebogamma/flebogamma Dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1575 |
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immunoglobulin |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1576 |
Injection, immune globulin (panzyga), intravenous,non-lyophilized (e.g., liquid), 500 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J1599 (Yimmugo) |
Yimmugo NDC 83372-0605-XX |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J1602 |
Injection, golimumab, 1mg, for intravenous use |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1628 |
Injection, guselkumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J1743 |
Injection, idursulfase, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1745 |
Injection, infliximab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J1786 |
Injection, imiglucerase, 10 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1823 |
Injection, inebilizumab-cdon, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1931 |
Injection, laronidase, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J1951 |
Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J2182 |
Injection, mepolizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2323 |
Injection, natalizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2326 |
Injection, nusinersen, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2327 |
Injection, risankizumab-rzaa, intravenous, 1mg (skyrizi) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J2329 |
Injection, ublituximab-xiiy, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J2350 |
Injection, ocrelizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2351 |
Injection, ocrelizumab, 1mg and hyaluronidase-ocsq |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
J2357 |
Injection, omalizumab, 5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2506 |
Injection, pegfilgrastim, excludes biosimilar, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J2507 |
Injection, pegloticase, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2508 |
Injection, pegunigalsidase alfa-iwxj, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J2778 |
Injection, ranibizumab, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2786 |
Injection, reslizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2793 |
Injection, rilonacept, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J2802 |
Injection, romiplostim, 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J2820 |
Injection, sargramostim (GM-CSF), 50 mcg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2840 |
Injection, sebelipase alfa, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J2998 |
Injection, plasminogen, human-tvmh, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3032 |
Injection, eptinezumab-jjmr, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J3055 |
Injection, talquetamab-tgvs, 0.25 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J3060 |
Injection, taliglucerase alfa, 10 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3111 |
Injection, romosozumab-aqqg, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
"This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J3241 |
Injection, teprotumumab-trbw, 10 mg |
Medical injectables/other non-injectable drugs |
Injection procedure |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3245 |
Injection, tildrakizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3262 |
Injection, tocilizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3285 |
Injection, treprostinil, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3357 |
Ustekinumab, for subcutaneous Injection, 1mg Injection |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
|
Yes |
No |
|
J3358 |
Ustekinumab for intravenous injection, 1mg
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3380 |
Injection, vedolizumab, intravenous 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3385 |
Injection, velaglucerase alfa, 100 units |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3392 |
Injection, exagamglogene autotemcel, per treatment |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3397 |
Injection, vestronidase alfa-vjbk, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J3398 |
Injection, voretigene neparvovec-rzyl, 1 billion vector genomes |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3399 |
Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5X10^15 vector genomes |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3401 |
Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector geomes, per 0.1ml |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J3490 (Rivfloza) |
rivfloza (nedosiran) ndc 0169-5308-01 ndc 0169-5307-08 ndc 0169-5306-10 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3490 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3490 (Tegsedi) |
Injection, tegsedi (inotersen) 1.5 ml in 1 syringe NDC 72126-007-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3490 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Alhemo) |
Alhemo (concizumab-mtci) NDC 0169-2084-15; 0169-2080-15; 0169-2081-03 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Avtozma IV) |
avtozma iv (tocilizumab-anoh) ndc: 72606-042-01; 72606-042-02; 72606-043-01; 72606-043-02; 72606-044-01; 72606-044-02 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Avtozma SQ) |
avtozma sq (tocilizumab-anoh) ndc: 72606-045-01; 72606-045-02; 72606-045-03; 72606-045-04; 72606-045-05; 72606-045-06 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Encelto) |
encelto (revakinagene taroretcel-lwey) ndc: 82958-501-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Entyvio SQ) |
Entyvio, subcutaneous (vedolizumab) ndc 64764-0107-11 ndc 64764-0108-21 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Enspryng) |
Enspryng (satralizumab) - NDC 50242-007-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Kebilidi) |
Kebilidi (eladocagene exuparvovec-tneq) ndc: 52856-601-01; 52856-601-11 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Lantidra) |
Lantidra (Donislecel-jujn) NDC 73539-001-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (OMISIRGE) |
Omisrge (Idubicel-onlv NDC 73441-800-04) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Tocilizumab-anoh IV) |
Unbranded biologic (tocilizumab-anoh iv ) ndc: 72606-048-01; 72606-048-02; 72606-049-01; 72606-049-02; 72606-050-01; 72606-050-02 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Tocilizumab-anoh SQ) |
unbranded biologic (tocilizumab-anoh sq) ndc: 72606-051-01; 72606-051-02; 72606-051-03; 72606-051-04; 72606-051-05; 72606-051-06 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Ryoncil) |
Ryoncil (remestemcel-l-rknd) NDC 73648-154-01; 73648-154-04 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Skysona) |
Skysona (elivaldogene autotemcel) NDC - 73554-2111-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Tyenne SQ) |
Tyenne Sq (Tocilizumab-Aazg) Ndc 65219-586-04; 65219-584-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Winrevair) |
WINREVAIR (SOTATERCEPT-SCRK) NDC 00006-5090-01; 00006-5087-01; 00006-5091-01; 00006-5088-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J3590 (Yesafili) |
Yesafili (aflibercept-jbvf) ndc 83257-013-11 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J9999 (Avzivi) |
Avzivi (bevacizumab-tnjn) NDC: 82143-001-01 NDC: 82143-002-01 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J9999 (Amtagvi) |
amtagvi (lifileucel) ndc 73776-001-11ndc 73776-001-12 |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150. |
Yes |
No |
|
J7179 |
Injection, von willebrand factor (recombinant), (vonvendi), 1 iu vwf:rco |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7170 |
Injection, emicizumab-kxwh, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7171 |
Injection, adamts13, recombinant-krhn, 10 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7172 |
injection, marstacimab-hncq, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7175 |
Injection, factor x, (human), 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7180 |
Injection, factor xiii (antihemophilic factor, human), 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7181 |
Injection, factor xiii a-subunit, (recombinant), per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7182 |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7183 |
Injection, von willebrand factor complex (human), wilate, 1 iu vwf:rco |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7185 |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7187 |
injection, von willebrand factor complex (humate-p), per iu vwf:rco |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7186 |
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7188 |
Injection, factor viii (antihemophilic factor, recombinant) (obizur), per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7189 |
Factor VIIA (Antihemophilic, Recombinant), (Novoseven rt), 1MCG |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7190 |
Factor viii (antihemophilic factor, human) per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7192 |
Factor viii (antihemophilic factor, recombinant) per iu, not otherwise specified |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7193 |
Factor ix (antihemophilic factor, purified, nonrecombinant) per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7194 |
factor ix complex, per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7195 |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
Medical injectables/ other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7194 |
Factor IX, Complex, per I.U. |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7198 |
Antiinhibitor, per I.U. |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7200 |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7201 |
Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7202 |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7203 |
Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7204 |
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7205 |
Injection, factor viii fc fusion protein (recombinant), per iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7207 |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 iu |
Medical injectables/ other non-injectable drugs. |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7208 |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi) 1 iu |
Medical injectables/ other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7209 |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7210 |
Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 iu |
Medical injectables/ other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7211 |
Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7212 |
Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 mcg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7213 |
Injection, coagulation factor ix (recombinant), ixinity, 1 iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7214 |
Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii iu |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J7318 |
Hyaluronan or derivative, durolane, for intra- articular injection, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7320 |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7321 |
Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7322 |
Hyaluronan or derivative, hymovis, for intra- articular injection, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMedss. |
Yes |
Yes |
|
J7324 |
Hyaluronan or derivative, orthovisc, for intra- articular injection, per dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7326 |
Hyaluronan or derivative, gel-one, for intra- articular injection, per dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7327 |
Hyaluronan or derivative, monovisc, for intra- articular injection, per dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7328 |
Hyaluronan or derivative, gel-syn, for intra- articular injection, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7329 |
Hyaluronan or derivative, trivisc, for intra- articular injection, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7330 |
Autologous cultured chondrocytes, implant |
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
J7331 |
Hyaluronan or derivative, SYNOJOYNT, for intra-articular injection, 1mg SYNOJOYNT and 1% sodium hyaluronate (J code for both drugs different NDC) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7332 |
Hyaluronan or derivative, TRILURON, for intra- articular injection, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J7352 |
Afamelanotide implant, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9015 |
Injection, aldesleukin, per single use vial |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J9021 |
Injection, asparaginase, recombinant, (rylaze), 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9022 |
Injection, atezolizumab, 10mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9023 |
Injection, avelumab, 10mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9024 |
Injection, atezolizumab, 5 mg and hyaluronidase-tqjs |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9026 |
Injection, tarlatamab, dlle, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9028 |
Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9033 |
Injection, bendamustine hydrochloride, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9034 |
Injection, Bendamustine Hcl (Bendeka), 1mg |
Medical Injectables/Other Non-Injectable Drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service. |
Yes |
No |
|
J9035 |
Injection, bevacizumab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9036 |
Injection, Bendamustine Hcl (Belrapzo/Bendamustine), 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
No |
|
J9038 |
Injection, axatilimab-csfr, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J9039 |
Injection, blinatumomab, 1 mcg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9042 |
Injection, brentuximab vedotin, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9043 |
Injection, cabazitaxel, 1mg (Jevtana) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9047 |
Injection carfilzomib 1mg (kyprolis) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9055 |
Injection, cetuximab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9056 |
Injection, Bendamustine Hcl (Vivimusta), 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9058 |
Injection, Bendamustine Hcl (Apotex), 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9059 |
Injection, Bendamustine Hcl (Baxter), 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9061 |
Injection, amivantamab-vmjw, 2 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9063 |
Injection, mirvetuximab soravtansine-gynx, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9064 |
Cabazitaxel (SANDOZ), not Therapeutically equivalent to J9043, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J9119 |
Injection, Cemiplimab-Rwlc, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9144 |
Injection, daratumumab, 10mg and hyaluronidase-fihj |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. |
Yes |
No |
|
J9145 |
Injection, daratumumab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9161 |
Injection, denileukin diftitox-cxdl, 1mcg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
Yes |
|
J9173 |
Injection, durvalumab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9176 |
Injection, elotuzumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J9203 |
Injection, gemtuzumab ozogamicin, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J9210 |
Injection, emapalumab-lzsg, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J9204 |
Injection, mogamulizumab-kpkc, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9223 |
Injection, lurbinectedin, 0.1mg (zepzelka) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9228 |
Injection, ipilimumab (yervoy), 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9247 |
Injection, melphalan flufenamide hcl, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J9264 |
Injection, paclitaxel protein-bound particles, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9271 |
Injection, pembrolizumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9272 |
Injection, dostarlimab-gxly, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9273 |
Injection, tisotumab vedotin-tftv, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9274 |
Injection, tebentafusp-tebn, 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9275 |
Injection, cosibelimab-ipdl, 2 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9276 |
Injection, zanidatamab-hrii, 2 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9289 |
Injection, nivolumab, 2 mg and hyaluronidase-nvhy |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9382 |
Injection, zenocutuzumab-zbco, 1 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9281 |
Mitomycin pyelocalyceal instillation, 1mg |
Medical injectables/other non-injectable drugs |
Injection procedure |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9286 |
Injection, glofitamab-gxbm, 2.5 mg |
Medical injectables/other non-injectable drugs |
Injection procedure |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9298 |
Injection, nivolumab and relatlimab-rmbw, 3 mg/1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9299 |
Injection, nivolumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9301 |
Injection, obinutuzumab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9302 |
Injection, ofatumumab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J9303 |
Injection, panitumumab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9305 |
Pemetrexed (alimta) |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J9306 |
Injection, Pertuzumab, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9308 |
Injection, ramucirumab, 5mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9309 |
Injection, polatuzumab vedotin-piiq, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9311 |
Injection, rituximab 10 mg and hyaluronidase |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9312 |
Injection, rituximab, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9316 |
Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9317 |
Injection, sacituzumab govitecan-hziy, 2.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
J9318 |
Injection, romidepsin, nonlyophilized, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9319 |
Injection, romidepsin, lyophilized, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This services is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9321 |
Injection, epcoritamab-bysp, 0.16mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9329 |
Injection, Tislelizumab-Jsgr, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9331 |
Injection, sirolimus protein-bound particles, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9332 |
Injection, efgartigimod alfa-fcab, 2mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthoirzed by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9333 |
Injection, rozanolixizumab-noli, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthoirzed by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9334 |
Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthoirzed by Capital Blue Cross for Commercial. |
Yes |
No |
|
J9345 |
Injection, Retifanlimab-dlwr, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
J9347 |
Injection, tremelimumab-actl, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9348 |
Injection, naxitamab-gqgk, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9349 |
Injection, tafasitamab-cxix, 2 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9354 |
Injection Ado-trastuzumab emtansine |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9355 |
Injection, Trastuzumab, excludes biosimilar, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9356 |
Injection, Trastuzumab, 10 mg and hyaluronidase-OYSK |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9358 |
Injection, fam-trastuzumab deruxtecan-nxki, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9359 |
Injection, loncastuximab tesirine-lpyl, 0.075 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9361 |
Injection, efbemalenograstim alfa-vuxw, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for commercial. |
Yes |
No |
|
J9376 |
Injection, pozelimab-bbfg, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for commercial. |
Yes |
No |
|
J9380 |
Injection, teclistamab-cqyv, 0.5mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9381 |
Injection, teplizumab-mzwv, 5mcg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
J9400 |
Injection, ZIV-aflibercept, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
K0002 |
Standard HEMI (low seat) wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0004 |
High strength, lightweight wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0005 |
Ultralightweight wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0006 |
Heavy-duty wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0007 |
Extra heavy-duty wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0008 |
Custom manual wheelchair/base |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0009 |
Other manual wheelchair/base |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0010 |
Standard-Weight frame motorized/power wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0011 |
Standard-Weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0012 |
Lightweight Portable motorized/power wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0013 |
Custom motorized/power wheelchair base |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0014 |
Other motorized/power wheelchair base |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0015 |
Detachable, Nonadjustable height armrest, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0017 |
Detachable, adjustable height armrest, base, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0018 |
Detachable, adjustable height armrest, upper portion, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0019 |
Arm pad, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0020 |
Fixed , adjustable height armrest, pair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0037 |
High mount flip-up footrest, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0038 |
Leg strap, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0039 |
Leg strap, H STYLE, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0040 |
Adjustable angle footplate, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0041 |
Large size footplate, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0042 |
Standard size footplate, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0043 |
Footrest, lower extension tube, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0044 |
Footrest, upper hanger bracket, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0045 |
Footrest, complete assembly |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0046 |
Elevating leg rest, lower extension tube, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0047 |
Elevating leg rest, upper hanger bracket, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0050 |
Ratchet assembly |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0051 |
Cam release assembly, footrest or leg rest, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0052 |
Swingway, Detachable footrests, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0056 |
Seat height less than 17 in or equal to or greater than 21 in for A high-strength, lightweight, or Ultra lightweight wheelchair |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0065 |
Spoke protectors, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0069 |
Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0070 |
Rear wheel assembly, complete, with pneumatic tire, spokes or molded, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0071 |
Front caster assembly, complete, with pneumatic tire, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0072 |
Front caster assembly, complete, with semi-pneumatic tire, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0073 |
Caster Pin lock, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0077 |
Front caster assembly, complete, with solid tire, replacement only, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0098 |
Drive belt for power wheelchair, replacement only |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0105 |
IV hanger, each |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0195 |
Elevating legrests, pair (for use with capped rental wheelchair base) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0462 |
Temporary replacement for patient-owned equipment being repaired, any type |
DME: equipment |
DME Rental |
|
Yes |
Yes |
|
K0606 |
Aed Garment W Elec Analysis |
DME: Defibrillator and supplies |
DME: Defibrillator and supplies |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
Yes |
|
K0669 |
Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
K0733 |
Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0739 |
Repair or non routine service for durable Medical equipment other than Oxygen equipment requiring the skill of a technician, labor component, per 15 minutes |
DME: equipment |
DME Repair |
|
Yes |
Yes |
|
K0744 |
Absorptive wound dressing for use with suction pump, home model, Portable, pad size 16 SQ in or less |
No category on the Professional COC - only facility |
Wound care |
|
Yes |
No |
|
K0745 |
Absorptive wound dressing for use with suction pump, home model, Portable, pad size more than 16 SQ in but less than or equal to 48 SQ in |
No category on the Professional COC - only facility |
Wound care |
|
Yes |
No |
|
K0746 |
Absorptive wound dressing for use with suction pump, home model, Portable, pad size, greater than 48 SQ in |
No category on the Professional COC - only facility |
Wound care |
|
Yes |
No |
|
K0800 |
Power operated Vehicle, group 1 standard, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0801 |
Power operated Vehicle, group 1 heavy-duty, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0802 |
Power operated Vehicle, group 1 very heavy-duty, patient Weight capacity 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0812 |
Power operated Vehicle, not otherwise classified |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0813 |
Power wheelchair, group 1 standard, Portable, sling/solid seat and back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0814 |
Power wheelchair, group 1 standard, Portable, captains chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0815 |
Power wheelchair, group 1 standard, sling/solid seat and back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0816 |
Power wheelchair, group 1 standard, captains chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0820 |
Power wheelchair, group 2 standard, Portable, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0821 |
Power wheelchair, group 2 standard, Portable, captains chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0822 |
Power wheelchair, group 2 standard, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0823 |
Power wheelchair, group 2 standard, captain's chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0824 |
Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0825 |
Power wheelchair, group 2 heavy-duty, captain's chair, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0826 |
Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient Weight capacity 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0827 |
Power wheelchair, group 2 very heavy duty, captains chair, patient Weight capacity 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0828 |
Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient Weight capacity 601 pounds or more |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0829 |
Power wheelchair, group 2 extra heavy duty, captains chair, patient Weight capacity 601 pounds or more |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0830 |
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
K0831 |
Power wheelchair, group 2 standard, seat elevator, captain's chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
No |
|
K0835 |
Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0836 |
Power wheelchair, group 2 standard, single power option, captain's chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0837 |
Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0838 |
Power wheelchair, group 2 heavy duty, single power option, captains chair, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0839 |
Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient Weight capacity 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0840 |
Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 601 pounds or more |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0841 |
Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0842 |
Power wheelchair, group 2 standard, multiple power option, captain's chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0843 |
Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0848 |
Power wheelchair, group 3 standard, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0849 |
Power wheelchair, group 3 standard, captain's chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0850 |
Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0851 |
Power wheelchair, group 3 heavy duty, captains chair, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0852 |
Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient Weight capacity 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0853 |
Power wheelchair, group 3 very heavy duty, captains chair, patient Weight capacity, 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0854 |
Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient Weight capacity 601 pounds or more |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0855 |
Power wheelchair, group 3 extra heavy duty, captains chair, patient Weight capacity 601 pounds or more |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0856 |
Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0857 |
Power wheelchair, group 3 standard, single power option, captain's chair, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0858 |
Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient Weight 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0859 |
Power wheelchair, group 3 heavy duty, single power option, captains chair, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0860 |
Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0861 |
Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0862 |
Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0863 |
Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 451 to 600 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0864 |
Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 601 pounds or more |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0890 |
Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient Weight capacity up to and including 125 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0891 |
Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 125 pounds |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0898 |
Power wheelchair, not otherwise classified |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0899 |
Power mobility device, not coded by DME PDAC or does not meet criteria |
DME: Wheelchairs and accessories |
Wheelchairs and accessories |
|
Yes |
Yes |
|
K0900 |
Customized durable Medical equipment, other than wheelchair |
DME: equipment |
DME Rental |
|
Yes |
Yes |
|
K1027 |
Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment |
DME: C-PAP and supplies |
DME device |
|
Yes |
Yes |
|
L0452 |
TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0480 |
TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0482 |
TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0484 |
TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0486 |
TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0622 |
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0624 |
Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0629 |
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, SHOU |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0632 |
Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0634 |
Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce LOA |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0636 |
Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid latera |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0638 |
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to R |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L0640 |
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to XYPHOID, produces intracavitary pressure to reduce load on the intervertebral |
DME: spinal orthotics |
Orthotics |
|
Yes |
No |
|
L1834 |
Knee orthotic (KO), without knee joint, rigid, custom fabricated |
Knee orthotics |
Orthotics |
|
Yes |
No |
|
L1840 |
Knee orthotic (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
Knee orthotics |
Orthotics |
|
Yes |
No |
|
L1844 |
Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated |
Knee orthotics |
Orthotics |
|
Yes |
No |
|
L1846 |
Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated |
Knee orthotics |
Orthotics |
|
Yes |
No |
|
L1900 |
Ankle foot orthosis, spring wire, dorsiflexion assist calf Band, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1904 |
Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1907 |
Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1920 |
Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1940 |
Ankle foot orthosis, plastic or other material , custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1945 |
Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1950 |
Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1952 |
Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, off-the-shelf |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1960 |
Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1970 |
Ankle foot orthosis, plastic with ankle joint, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1980 |
Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf Band/cuff (single BAR 'BK' orthosis), custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L1990 |
Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf Band/cuff (double bar 'BK' orthosis), custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2000 |
Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single BAR 'AK' orthosis), custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2005 |
Knee ankle foot orthosis, any material, single or double upright, stance control, Automatic lock and Swing phase release, any type activation, includes ankle joint, any type, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2006 |
Knee ankle foot device, any material, single or double upright, Swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), Custom F |
DME: ankle, foot and knee orthotics |
DME device |
|
Yes |
No |
|
L2010 |
Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single BAR 'AK' orthosis), without knee joint, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2020 |
Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'AK' orthosis), custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2030 |
Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'AK' orthosis), without knee joint, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2034 |
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2036 |
Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2037 |
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2038 |
Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2106 |
Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material , custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2108 |
Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2126 |
Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material , custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L2128 |
Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L4205 |
Repair of orthotic device, labor component, per 15 minutes |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L4210 |
Repair of orthotic device, repair or replace minor parts |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L4631 |
Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material , includes straps and closures, custom fabricated |
DME: ankle, foot and knee orthotics |
Orthotics |
|
Yes |
No |
|
L5000 |
Partial foot, shoe insert with longitudinal arch, toe filler |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5010 |
Partial foot, molded socket, ankle height, with toe filler |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5020 |
Partial foot, molded socket, tibial tubercle height, with toe filler |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5050 |
Ankle, symes, molded socket, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5060 |
Ankle, symes, metal frame, molded leather socket, articulated ankle/foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5100 |
Below knee, molded socket, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5105 |
Below knee, plastic socket, joints and thigh lacer, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5150 |
Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5160 |
Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5200 |
Above knee, molded socket, single axis constant friction knee, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5210 |
Above knee, short prosthesis, No knee joint ('stubbies'), with foot blocks, No ankle joints, each |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5220 |
Above knee, short prosthesis, No knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5230 |
Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5250 |
Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5270 |
Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5280 |
Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5301 |
Below knee, molded socket, shin, sach foot, endoskeletal system |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5312 |
Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5321 |
Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5331 |
Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5341 |
Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5500 |
Initial, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, direct formed |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5505 |
Initial, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, direct formed |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5510 |
Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, molded to model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5520 |
Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, direct formed |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5530 |
Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, molded to model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5535 |
Preparatory, below knee 'PTB' type socket, Non-alignable system, No cover, sach foot, prefabricated, adjustable open end socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5540 |
Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, laminated socket, molded to model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5560 |
Preparatory, above knee- knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, molded to model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5570 |
Preparatory, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, direct formed |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5580 |
Preparatory, above knee - knee disarticulation ischial level socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, molded to model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5585 |
Preparatory, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, prefabricated adjustable open end socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5590 |
Preparatory, above knee - knee disarticulation ischial level socket, Non-alignable system, pylon no cover, sach foot, laminated socket, molded to model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5595 |
Preparatory, hip disarticulation hemipelvectomy, pylon, No cover, sach foot, thermoplastic or equal, molded to patient model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5600 |
Preparatory, hip disarticulation hemipelvectomy, pylon, No cover, sach foot, laminated socket, molded to patient model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5610 |
Addition to lower extremity, endoskeletal system, above knee, hydracadence system |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5611 |
Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5613 |
Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5614 |
Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L5616 |
Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5618 |
Addition to lower extremity, test socket, symes |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5620 |
Addition to lower extremity, test socket, below knee |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5622 |
Addition to lower extremity, test socket, knee disarticulation |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5624 |
Addition to lower extremity, test socket, above knee |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5626 |
Addition to lower extremity, test socket, hip disarticulation |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5628 |
Addition to lower extremity, test socket, hemipelvectomy |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5629 |
Addition to lower extremity, below knee, acrylic socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5630 |
Addition to lower extremity, symes type, expandable wall socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5631 |
Addition to lower extremity, above knee or knee disarticulation, acrylic socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5632 |
Addition to lower extremity, symes type, 'PTB' brim design socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5634 |
Addition to lower extremity, symes type, posterior opening (Canadian) socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5636 |
Addition to lower extremity, symes type, medial opening socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5638 |
Addition to lower extremity, below knee, leather socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5639 |
Addition to lower extremity, below knee, wood socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5640 |
Addition to lower extremity, knee disarticulation, leather socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5642 |
Addition to lower extremity, above knee, leather socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5643 |
Addition to lower extremity, hip disarticulation, flexible inner socket, external frame |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5644 |
Addition to lower extremity, above knee, wood socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5645 |
Addition to lower extremity, below knee, flexible inner socket, external frame |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5646 |
Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5647 |
Addition to lower extremity, below knee suction socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5648 |
Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5649 |
Addition to lower extremity, ischial containment/narrow M-L socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5650 |
Additions to lower extremity, total contact, above knee or knee disarticulation socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5651 |
Addition to lower extremity, above knee, flexible inner socket, external frame |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5652 |
Addition to lower extremity, suction suspension, above knee or knee disarticulation socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5653 |
Addition to lower extremity, knee disarticulation, expandable wall socket |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5654 |
Addition to lower extremity, socket insert, symes, (kemlo, pelite, aliplast, plastazote or equal) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5655 |
Addition to lower extremity, socket insert, below knee (kemlo, pelite, aliplast, plastazote or equal) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5656 |
Addition to lower extremity, socket insert, knee disarticulation (kemlo, pelite, aliplast, plastazote or equal) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5658 |
Addition to lower extremity, socket insert, above knee (kemlo, pelite, aliplast, plastazote or equal) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5661 |
Addition to lower extremity, socket insert, multi-durometer symes |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5665 |
Addition to lower extremity, socket insert, multi-durometer, below knee |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5666 |
Addition to lower extremity, below knee, cuff suspension |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5668 |
Addition to lower extremity, below knee, molded distal cushion |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5670 |
Addition to lower extremity, below knee, molded supracondylar suspension ('PTS' or similar) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5671 |
Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5672 |
Addition to lower extremity, below knee, removable medial brim suspension |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5673 |
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5679 |
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5681 |
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5683 |
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5700 |
Replacement, socket, below knee, molded to patient model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5701 |
Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5702 |
Replacement, socket, hip disarticulation, including hip joint, molded to patient model |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5703 |
Ankle, symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5704 |
Custom shaped protective cover, below knee |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5710 |
Addition, exoskeletal knee-shin system, single axis, manual lock |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5711 |
Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light-material |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5712 |
Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5714 |
Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5716 |
Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5718 |
Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5781 |
Addition to lower limb prothesis, vacuum pump, residual limb volume management and moisture evacuation system |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5782 |
Addition to lower limb prothesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5810 |
Addition, endoskeletal, knee-shin system, single axis, manual lock |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5811 |
Addition, endoskeletal, knee-shin system, single axis, manual lock, ultra-light-material |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5812 |
Addition, endoskeletal, knee-shin system, single axis, friction swing and stance phase control (safety knee) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5814 |
Addition, endoskeletal, knee-shin system, polycentric, hydraulic swing phase control , mechanical stance phase lock |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5816 |
Addition, endoskeletal, knee-shin system, polycentric, mechanical stance phase lock |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5818 |
Addition, endoskeletal, knee-shin system, polycentric, friction swing, and stance phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5822 |
Addition, endoskeletal, knee-shin system, single axis, pneumatic swing, friction stance phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5824 |
Addition, endoskeletal, knee-shin system, single axis, fluid swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5826 |
Addition, endoskeletal, knee-shin system, single axis, hydraulic swing phase control , with miniature high activity frame |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5827 |
Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5828 |
Addition, endoskeletal, knee-shin system, single axis, fluid swing and stance phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5830 |
Addition, endoskeletal, knee-shin system, single axis, pneumatic/ Swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5840 |
Addition, endoskeletal knee/shin system, 4-BAR linkage or multiaxial, pneumatic swing phase control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5845 |
Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5848 |
Addition to endoskeletal knee-shin system, FLUID stance extension, dampening feature, with or without adjustability |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5856 |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, Swing and stance phase, includes electronic sensor(s), any type |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5857 |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, Swing phase only, includes electronic sensor(s), any type |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5858 |
Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5859 |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5920 |
Addition, endoskeletal system, above knee or hip disarticulation, alignable system |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5930 |
Addition, endoskeletal system, high activity knee control frame |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5950 |
Addition, endoskeletal system, above knee, ultralight material (titanium, carbon fiber or equal) - |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5961 |
Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5970 |
All lower extremity prostheses, foot, external keel, sach foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5972 |
All lower extremity prostheses, foot, flexible keel |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5974 |
All lower extremity prostheses, foot, single axis ankle/foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5976 |
All lower extremity prostheses, energy Storing foot (seattle carbon copy II or equal) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5978 |
All lower extremity prostheses, foot, multiaxial ankle/foot |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5979 |
All lower extremity prosthesis, multi-axial ankle, dynamic response foot, one piece system |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5980 |
All lower extremity prostheses, flex foot system |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5981 |
All lower extremity prostheses, flex-walk system or equal |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5982 |
All exoskeletal lower extremity prostheses, axial rotation unit |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5984 |
All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5986 |
All lower extremity prostheses, multi-axial rotation unit ('MCP' or equal) |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5987 |
All lower extremity prosthesis, shank foot system with vertical loading pylon |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L5991 |
Addition to lower extremity prosthesis, Osseointegrated External Prosthetic Connector |
Lower extremity: Prosthetics |
Prosthetics |
|
Yes |
No |
|
L6000 |
Partial hand, thumb remaining |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6010 |
Partial hand, little and/or ring finger remaining |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6020 |
Partial hand, No finger remaining |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6028 |
Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power, not including inserts described by l6692 |
DME: Prosthetic appliances and implants |
Prosthetics |
|
Yes |
Yes |
|
L6037 |
Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers |
Upper extermity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6050 |
Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6055 |
Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6100 |
Below elbow, molded socket, flexible elbow hinge, triceps pad |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6110 |
Below elbow, molded socket, (muenster or northwestern suspension types) |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6120 |
Below elbow, molded double wall split socket, STEP-up hinges, half cuff |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6130 |
Below elbow, molded double wall split socket, stump activated locking hinge, half cuff |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6200 |
Elbow disarticulation, molded socket, outside locking hinge, forearm |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6205 |
Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6250 |
Above elbow, molded double wall socket, internal locking elbow, forearm |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6300 |
Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6310 |
Shoulder disarticulation, passive restoration (complete prosthesis) |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6320 |
Shoulder disarticulation, passive restoration (shoulder CAP only) |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6350 |
Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6360 |
Interscapular thoracic, passive restoration (complete prosthesis) |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6370 |
Interscapular thoracic, passive restoration (shoulder CAP only) |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6400 |
Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6450 |
Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6500 |
Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6550 |
Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6570 |
Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6580 |
Preparatory, wrist disarticulation or below elbow, single Wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, USMC or equal pylon, No cover, molded to patient model |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6582 |
Preparatory, wrist disarticulation or below elbow, single Wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, USMC or equal pylon, No cover, direct formed |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6584 |
Preparatory, elbow disarticulation or above elbow, single Wall plastic socket, friction wrist, locking elbow, figure of eight harness, Fair lead cable control, USMC or equal pylon, No cover, molded to patient model |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6586 |
Preparatory, elbow disarticulation or above elbow, single Wall socket, friction wrist, locking elbow, figure of eight harness, Fair lead cable control, USMC or equal pylon, No cover, direct formed |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6588 |
Preparatory, shoulder disarticulation or interscapular thoracic, single Wall plastic socket, shoulder joint, locking elbow, friction wrist, Chest strap, Fair lead cable control, USMC or equal pylon, No cover, molded to patient model |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6590 |
Preparatory, shoulder disarticulation or interscapular thoracic, single Wall socket, shoulder joint, locking elbow, friction wrist, Chest strap, Fair lead cable control, USMC or equal pylon, No cover, direct formed |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6700 |
Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition decoding intent movement |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6703 |
Terminal device, passive hand/MITT, any material, any size |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6704 |
Terminal device, Sport/recreational/work attachment, any material, any size |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6706 |
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6707 |
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6708 |
Terminal device, hand, mechanical, voluntary opening, any material, any size |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6709 |
Terminal device, hand, mechanical, voluntary closing, any material, any size |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6711 |
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6712 |
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6713 |
Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6714 |
Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6721 |
Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6722 |
Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6881 |
Automatic grasp feature, addition to upper limb electric prosthetic terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6882 |
Microprocessor control feature, addition to upper limb prosthetic terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6883 |
Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6884 |
Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6885 |
Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6900 |
Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6905 |
Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6910 |
Hand restoration (casts, shading and measurements included), partial hand, with glove, No fingers remaining |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6915 |
Hand restoration (shading, and measurements included), replacement glove for above |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6920 |
Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6925 |
Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6930 |
Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6935 |
Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6940 |
Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
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, myoelectric control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6950 |
Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
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, myoelectric control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6960 |
Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
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, myoelectric control of terminal |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L6970 |
Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
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, myoelectric control of terminal D |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7007 |
Electric hand, switch or myoelectric controlled, adult |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7008 |
Electric hand, switch or myoelectric, controlled, pediatric |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7009 |
Electric hook, switch or myoelectric controlled, adult |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7040 |
Prehensile actuator, switch controlled |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7045 |
Electric hook, switch or myoelectric controlled, pediatric |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7170 |
Electronic elbow, hosmer or equal, switch controlled |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7180 |
Electronic elbow, microprocessor sequential control of elbow and terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7181 |
Electronic elbow, microprocessor Simultaneous control of elbow and terminal device |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7185 |
Electronic elbow, adolescent, variety village or equal, switch controlled |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7186 |
Electronic elbow, child, variety village or equal, switch controlled |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7190 |
Electronic elbow, adolescent, variety village or equal, myoelectric-controlled controlled |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7191 |
Electronic elbow, child, variety village or equal, myoelectric-controlled controlled |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L7259 |
Electronic wrist rotator, any type |
Upper extremity prosthetics |
Prosthetics |
|
Yes |
Yes |
|
L8641 |
Metatarsal Joint Implant |
Outpatient Surgery For Select Procedures |
Surgery- Musculoskeletal |
|
Yes |
No |
|
L8642 |
Hallux Implant |
Outpatient Surgery For Select Procedures |
Surgery- Musculoskeletal |
|
Yes |
No |
|
L8699 |
Prosthetic Implant, Not Otherwise Specified |
Outpatient Surgery For Select Procedures |
Surgery- Musculoskeletal |
|
Yes |
No |
|
L8600 |
Implantable breast prosthesis, silicone or equal |
Reconstructive or cosmetic services - breast procedures |
Surgery - breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
|
L8612 |
Aqueous shunt |
DME: implant |
DME Implant |
|
Yes |
Yes |
|
L8679 |
Implantable neurostimulator , pulse generator, any type [when specified as sacral Nerve stimulator] |
DME: implant |
Nerve stimulator |
|
Yes |
Yes |
|
L8680 |
Implantable neurostimulator electrode, each |
DME: implant |
Nerve stimulator |
|
Yes |
Yes |
|
L8681 |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only |
Implant Supply |
Nerve stimulator |
|
Yes |
Yes |
|
L8682 |
Implantable neurostimulator radiofrequency receiver |
DME: implant |
Nerve stimulator |
|
Yes |
Yes |
|
L8683 |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
Implant Supply |
Nerve stimulator |
|
Yes |
Yes |
|
L8684 |
Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement |
Implant Supply |
Nerve stimulator |
|
Yes |
Yes |
|
L8685 |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
DME: implant |
Nerve stimulator |
|
Yes |
Yes |
|
L8686 |
Implantable neurostimulator pulse generator, single array, No rechargeable, includes extension |
DME: implant |
Nerve stimulator |
|
Yes |
Yes |
|
L8687 |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
DME: implant |
Nerve stimulator |
|
Yes |
Yes |
|
L8688 |
Implantable neurostimulator pulse generator, dual array, Nonrechargeable, includes extension |
DME: implant |
Nerve stimulator |
|
Yes |
Yes |
|
L8689 |
External recharging system for battery (internal) for use with implantable neurostimulator , replacement only |
Implant Supply |
DME supplies |
|
Yes |
Yes |
|
L8693 |
Prosthetic Implant, Not Otherwise Specified |
Outpatient Surgery For Select Procedures |
Surgery- Musculoskeletal |
|
Yes |
No |
|
Q0138 |
Inection, ferumoxytol, for treatment of iron deficiency anemia, 1mg (non-esrd use) |
Medical injectables/other non-injectable drugs |
Medical specialty drugs |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
Q2041 |
Axicabtagene ciloleucel, up to 200 million Autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation Procedures, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q2042 |
Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation Procedures, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q2043 |
SIPULEUCEL-T, minimum of 50 million Autologous CD54+ cells activate with PAP-GM-CSF, including leukapheresis and all other Preparatory Procedures, per infusion |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
No |
Yes |
|
Q2053 |
Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q2054 |
Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q2055 |
Idecabtagene vicleucel, up to 510 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q2056 |
Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q2057 |
Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q2058 |
Obecabtagene autoleucel, 10 up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5098 |
Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5099 |
Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5100 |
Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5101 |
Injection, filgrastim -sndz, biosimilar, (zarxio) 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5103 |
Injection, infliximab-dyyb, biosimilar, (inflectra), 10mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5104 |
Injection, infliximab-abda, biosimilar (renflexis), 10mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5107 |
Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5108 |
Injection, pegfilgrastim-jmdb, (fulphila), biosimilar,0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5110 |
Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5111 |
Injection, pegfilgrastim-cbqv, (udenyca), biosimilar, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5112 |
Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5113 |
Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5114 |
Injection, trastuzumab-dkst, biosimilar, (OGIVRI), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5115 |
Injection, rituximab-abbs, biosimilar (truxima), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5116 |
Injection, Trastuzumab-Qyyp, Biosimilar, (Trazimera), 10 Mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5117 |
Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5118 |
Injection, bevacizumab-bzvr, biosimilar, (zirabev), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5119 |
Injection, rituximab-pvvr, biosimilar (RUXIENCE), 10 mg |
Medical injectables/other non-injectable drugs |
Injection procedure |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
|
Q5120 |
Injection, pegfilgrastim-bmez, (ZIEXTENZO), biosimilar, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
Q5121 |
Injection, infliximab-AXXQ, biosimilar, (AVSOLA), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5122 |
Injection, pegfilgrastim-apgf, (nyvepria), biosimilar, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5123 |
Injection, rituximab-arrx, biosimilar, (riabni), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5124 |
Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5125 |
Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5126 |
Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5127 |
Injection, pegfilgrastim-FPGK (stimufend), biosimilar, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5128 |
Injection, ranibizumab-EQRN (cimeril), biosimilar, 0.1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5129 |
Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5130 |
Injection, pegfiLgrastim-PBBK (fylnetra), biosimilar, 0.5 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5133 |
Injection, tocilizumab-bavi(tofidence), biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5134 |
Injection, natalizumab-sztn, biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5135 |
Injection, Tocilizumab-Aazg (Tyenne), Biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5136 |
Injection, Denosumab-Bbdz (Jubbonti/Wyost), Biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5137 |
Injection, ustekinumab-aaub (wezlana), biosimilar, subcutaneous, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5138 |
Injection, ustekinumab-aaub (wezlana), biosimilar, intravenous, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5146 |
Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
Q5147 |
Injection, aflibercept-ayyh (pavblu), biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5148 |
Injection, filgrastim-txid (nypozi), biosimilar, 1 microgram |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
Q5149 |
Injection, aflibercept-abzv (enzeevu), biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5150 |
Injection, aflibercept-mrbb (ahzantive), biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q5151 |
Injection, eculizumab-aagh (epysqli), biosimilar, 2mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
Q5152 |
Injection, eculizumab-aeeb (bkemv), biosimilar, 2mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds. |
Yes |
Yes |
|
Q5153 |
Injection, aflibercept-yszy (opuviz), biosimilar, 1 mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q9996 |
Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. |
Yes |
No |
|
Q9997 |
Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
Q9998 |
Injection, ustekinumab-aekn (selarsdi), biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
Q9999 |
Injection, ustekinumab-aauz (otulfi), biosimilar, 1mg |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Medicare Advantage through CoverMyMeds |
Yes |
Yes |
|
S0157 |
Becaplermin gel 0.01%, 0.5 GM |
Investigational and experimental procedures |
Wound care |
Not valid for Medicare |
Yes |
No |
|
S0201 |
partial hospitalization services, less than 24 hours, per diem |
select outpatient behavioral health services |
behavioral health services |
Not valid for Medicare purposes. |
Yes |
No |
|
S0812 |
Phototherapeutic keratectomy (PTK) |
Outpatient surgery for select procedures |
Surgery - Eye |
Not valid for Medicare |
Yes |
No |
|
S1034 |
Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, Blood glucose device, insulin pump and computer algorithm that communicates with all of the devices |
Diabetic DME & supplies |
Diabetic Supplies |
|
Yes |
No |
|
S1035 |
Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system |
Diabetic DME & supplies |
DME supplies |
|
Yes |
No |
|
S1036 |
Transmitter; external, for use with artificial pancreas device system |
Diabetic DME & supplies |
DME supplies |
|
Yes |
No |
|
S1037 |
Receiver (monitor); external, for use with artificial pancreas device system |
Diabetic DME & supplies |
DME supplies |
|
Yes |
No |
|
S1040 |
Cranial remolding orthotic, pediatric, rigid, with soft interface material , custom fabricated, includes fitting and adjustment(s) |
DME: equipment |
Orthotics |
|
Yes |
No |
|
S2053 |
Transplantation of small intestine, and liver allografts |
Transplant surgeries |
Organ/Tissue transplant - Intestine and Liver |
Not valid for Medicare |
Yes |
No |
|
S2054 |
Transplantation of multivisceral organs |
Transplant surgeries |
Organ/Tissue transplant - Multiple Organs |
Not valid for Medicare |
Yes |
No |
|
S2055 |
Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor |
Transplant surgeries |
Organ/Tissue transplant - Multiple Organs |
Not valid for Medicare |
Yes |
No |
|
S2060 |
Lobar lung transplantation |
Transplant surgeries |
Organ/Tissue transplant - Lung |
Not valid for Medicare |
Yes |
No |
|
S2061 |
Donor lobectomy (lung) for transplantation, living donor |
Transplant surgeries |
Organ/Tissue transplant - Lung |
Not valid for Medicare |
Yes |
No |
|
S2065 |
Simultaneous pancreas kidney transplantation |
Transplant surgeries |
Organ/Tissue transplant - Kidney |
Not valid for Medicare |
Yes |
No |
|
S2066 |
Breast reconstruction with gluteal artery perforator (gap) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral |
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauth NOT REQUIRED for treatment of cancer. Not valid for Medicare |
Yes |
No |
|
S2067 |
Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral |
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauth NOT REQUIRED for treatment of cancer. Not valid for Medicare |
Yes |
No |
|
S2068 |
Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral |
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast Procedures |
Preauth NOT REQUIRED for treatment of cancer. Not valid for Medicare |
Yes |
No |
|
S2083 |
Adjustment of Gastric Band diameter via subcutaneous port by injection or aspiration of Saline |
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
Not valid for Medicare |
Yes |
No |
|
S2112 |
Arthroscopy, knee, Surgical for Harvesting of Cartilage (Chondrocyte cells) |
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2118 |
Metal-on-metal total hip resurfacing, including acetabular and femoral components |
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2140 |
Cord Blood Harvesting for transplantation, allogeneic |
Transplant surgeries |
Blood or marrow stem cell transplants |
Not valid for Medicare |
Yes |
No |
|
S2142 |
Cord Blood-derived stem-cell transplantation, allogeneic |
Transplant surgeries |
Blood or marrow stem cell transplants |
Not valid for Medicare |
Yes |
No |
|
S2150 |
Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and posttransplant care in the global definition |
Transplant surgeries |
Blood or marrow stem cell transplants |
Not valid for Medicare |
Yes |
No |
|
S2152 |
Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition |
Transplant surgeries |
Organ/Tissue transplant |
Not valid for Medicare |
Yes |
No |
|
S2202 |
Echosclerotherapy |
Reconstructive or cosmetic services: Varicose veins |
Varicose vein procedure |
Not valid for Medicare |
Yes |
No |
|
S2205 |
Minimally Invasive Direct Coronary Artery Bypass Surgery Involving Mini-Thoracotomy Or Mini-Sternotomy Surgery, Performed Under Direct Vision; Using Arterial Graft(S), Single Coronary Arterial Graft |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2206 |
Minimally Invasive Direct Coronary Artery Bypass Surgery Involving Mini-Thoracotomy Or Mini-Sternotomy Surgery, Performed Under Direct Vision; Using Arterial Graft(S), Two Coronary Arterial Grafts |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2207 |
Minimally Invasive Direct Coronary Artery Bypass Surgery Involving Mini-Thoracotomy Or Mini-Sternotomy Surgery, Performed Under Direct Vision; Using Two Arterial Grafts And Single Venous Graft |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2208 |
Minimally Invasive Direct Coronary Artery Bypass Surgery Involving Mini-Thoracotomy Or Mini-Sternotomy Surgery, Performed Under Direct Vision; Using Single Arterial And Venous Graft(S), Single Venous Graft |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2209 |
Minimally Invasive Direct Coronary Artery Bypass Surgery Involving Mini-Thoracotomy Or Mini-Sternotomy Surgery, Performed Under Direct Vision; Using Two Arterial Grafts And Single Venous Graft |
Select diagnostic and surgical cardiology services |
Surgery/procedure-cardiovascular |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2230 |
Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear |
DME; Prosthetic appliance and implants |
Hearing testing and treatment |
|
Yes |
No |
|
S2348 |
Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar |
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2350 |
Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace |
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S2351 |
Diskectomy ant w/osteophytes; lumbar ed add in interspace |
Surgery for select procedures |
Surgery - Musculoskeletal |
Preauthorization is required through TurningPoint at 844.540.3705 or myturningpoint-healthcare.com. |
Yes |
No |
|
S3800 |
Genetic testing for Amyotrophic Lateral Sclerosis (ALS) |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3844 |
DNA analysis of the connexin 26 Gene (GJB2) for susceptibility to congenital, profound deafness |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3845 |
Genetic testing for alpha-thalassemia |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3846 |
Genetic testing for hemoglobin E beta-thalassemia |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3850 |
Genetic testing for sickle cell anemia |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3853 |
Genetic testing for myotonic muscular dystrophy |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3861 |
Genetic testing, sodium channel, voltage-gated, Type V, Alpha Subunit (SCN5A) and variants for suspected Brugada Syndrome |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3866 |
Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S3870 |
Comparative genomic hybridization (CGH) microarray testing for developmental delay, Autism Spectrum Disorder and/or intellectual disability |
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Not valid for Medicare |
Yes |
No |
|
S8037 |
Magnetic Resonance Cholangiopancreatography (MRCP) |
Diagnostic services: MRCP Scans |
X-Ray/Imaging -MRI Scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
No |
|
S8092 |
Electron beam computed tomography (Also known as Ultrafast CT, Cine CT) |
Diagnostic services: CT scans |
Investigational X-Ray/Imaging Cat Scan |
Preauthorization may be required. Please contact Evolent at 844.540.3705 or via web portal at RadMD.com. |
Yes |
No |
|
S8948 |
Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes |
other services: laser treatment |
skin procedure |
|
Yes |
No |
|
S8950 |
Complex Lymphedema therapy, each 15 minutes |
Investigational and experimental procedures |
Lymphedema therapy |
Not valid for Medicare |
Yes |
No |
|
S9055 |
Procuren or other growth factor preparation to promote wound healing |
Investigational and experimental procedures |
Wound care |
Not valid for Medicare |
Yes |
No |
|
S9340 |
Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem |
Other services: enteral feeding and supplies |
Special nutrient formula |
Not valid for Medicare |
Yes |
No |
|
S9341 |
Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem |
Other services: enteral feeding and supplies |
Special nutrient formula |
Not valid for Medicare |
Yes |
No |
|
S9342 |
Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem |
Other services: enteral feeding and supplies |
Special nutrient formula |
Not valid for Medicare |
Yes |
No |
|
S9343 |
Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem |
Other services: enteral feeding and supplies |
Special nutrient formula |
Not valid for Medicare |
Yes |
No |
|
S9433 |
Medical food nutritionally complete, administered orally, providing 100% of nutritional intake |
Other services: enteral feeding and supplies |
Special nutrient formula |
Not valid for Medicare |
Yes |
No |
|
S9434 |
Modified solid food supplements for inborn errors of metabolism |
Other services: enteral feeding and supplies |
Special nutrient formula |
Not valid for Medicare |
Yes |
No |
|
S9435 |
Medical foods for inborn errors of metabolism |
Other services: enteral feeding and supplies |
Special nutrient formula |
Not valid for Medicare |
Yes |
No |
|
S9480 |
Intensive outpatient psychiatric services, per diem |
Select outpatient behavioral health services |
Behavioral health services |
Not valid for Medicare purposes. |
Yes |
No |
|
S9960 |
Ambulance service, conventional air services, non emergency transport, one way (fixed wing) |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
Not valid for Medicare |
Yes |
No |
|
S9961 |
Ambulance service, conventional air service, non emergency transport, one way (rotary wing) |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
Not valid for Medicare |
Yes |
No |
|
T2007 |
Transportation waiting time, air ambulance and non-emergency vehicle, one-half (1/2) hour increments |
Other services: ambulance services - non emergent |
Non emergency ambulance transport |
|
Yes |
Yes |
|
V2785 |
Processing, preserving and transporting corneal tissue |
Transplant surgeries |
Organ/Tissue transplant |
|
Yes |
Yes |
|
V5095 |
Semi-implantable middle ear hearing prosthesis |
DME; Prosthetic appliance and implants |
Hearing testing and treatment |
|
Yes |
No |