Single Source Preauthorization List

This information is not a guarantee of payment.

Benefits are subject to limitations in a member’s Certificate of Coverage and the member’s eligibility status.

The information being provided is based on information currently available in Capital BlueCross' files.

Payment or processing of actual claims is subject to a determination regarding 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 on this computer system is proprietary and confidential to Capital BlueCross 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. Please refer to the web or published manuals for a description of the service.
  • Preauthorization is required for the following list of items that are not necessarily listed separately by code: All inpatient admissions and observation care over 48 hours; services/items that are considered by Capital BlueCross medical policy to be Experimental/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.
  • Effective 1/1/2020 DME/Orthotics/Prosthetic items requiring Preauthorization will be individually listed below on the Single Source Preauthorization Code list. If the service is found, Preauthorization is required on rentals and/or purchases. If not found below, then the DME service does not require Preauthorization.
  • Preauthorization does not generally apply to services/items that are specifically excluded from coverage under the Member’s Certificate of Coverage. Therefore, these items may not appear on the preauthorization list.
  • All services that are considered investigational/experimental 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 BlueCross Medical Policy (or its delegated vendor) for medical necessity information.
  • Refer to Medical Policy 3.015 entitled "Office-Based Procedures Performed in a Facility" which is available on the Capital BlueCross Medical Policy website for a list of services that require preauthorization when performed in a facility. These procedures can be safely performed in an office setting for most patients. Individual consideration can be given in the form of preauthorization for unique member conditions as outlined in the Medical Policy.
  • 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 below.

Download the Single Source Preauthorization Code List

Code HCPCS and Dental Code Description Preauthorization Category Type of Care Comments Commercial BlueJourney

0001U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0003U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0005U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0009M

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0009U

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

 

Yes

Yes

0012U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0013U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0014U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0016U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0017U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0018U

 

Investigational and Experimental Procedures

Diagnostic Services : Genetic Testing

For BlueJourney covered if medically Necessary

Yes

Yes

0019U

 

Investigational and Experimental Procedures

Lab/Genetic Testing

For BlueJourney covered if medically Necessary

Yes

Yes

0021U

 

Investigational and Experimental Procedures

Lab/Genetic Testing

 

Yes

Yes

0023U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0026U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0027U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0029U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

0040U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0042T

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). Traditional Products do not require Preauth

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

No

Yes

0049U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0078U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0084U

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

0129U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0130U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0131U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0132U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0133U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0134U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0135U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0136U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0137U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

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

0163T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0165T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

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

Yes

0173U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

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

0191T

 

Investigational and Experimental Procedures

Investigational eye procedures

 

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

Yes

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

This service is preauthorized through Turning Point

Yes

Yes

0200U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0201T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0201U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0202T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0204U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0208U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0212U

 

Diagnostic Services: MRI

Diagnostic Services: MRI

 

Yes

Yes

0213U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0219T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0220T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0221T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0222T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0253T

 

Outpatient Surgery for Select Procedures

Surgery - Eye

 

Yes

Yes

0274T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0275T

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

0345T

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

No

0362T

 

Investigational and Experimental Procedures

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

0373T

 

Investigational and Experimental Procedures

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

0376T

 

Outpatient Surgery for Select Procedures

Investigational eye procedures

 

Yes

Yes

0394T

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

0395T

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

0402T

 

New to market service

New Technology

 

Yes

Yes

0413

 

Therapy services: Hyperbaric Oxygen

Hyperbaric Oxygen

Facility revenue code requires preauthorization.

Yes

Yes

0420

 

Therapy services: Physical therapy

Physical therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0421

 

Therapy services: Physical therapy

Physical therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0422

 

Therapy services: Physical therapy

Physical therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0423

 

Therapy services: Physical therapy

Physical therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0424

 

Therapy services: Physical therapy

Physical therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0429

 

Therapy services: Physical therapy

Physical therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0430

 

Investigational and Experimental Procedures

Occupational therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0431

 

Therapy services: Hyperbaric Oxygen

Occupational therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0432

 

Therapy services: Occupational therapy

Occupational therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0433

 

Therapy services: Occupational therapy

Occupational therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0434

 

Therapy services: Hyperbaric Oxygen

Occupational therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0439

 

Therapy services: Occupational therapy

Occupational therapy services

Facility revenue code requires preauthorization.

Yes

Yes

0441T

 

New to market service

New Technology

 

 

Yes

Yes

0449T

 

Investigational and Experimental Procedures

Investigational eye procedures

 

Yes

Yes

0450T

 

Investigational and Experimental Procedures

Investigational eye procedures

 

Yes

Yes

0466T

 

Outpatient Surgery for Select Procedures

Surgery - Chest

 

Yes

No

0467T

 

Outpatient Surgery for Select Procedures

Surgery - Chest

 

Yes

No

0474T

 

Investigational and Experimental Procedures

Investigational eye procedures

 

Yes

Yes

0483T

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

No

0524T

 

Reconstructive or Cosmetic services: Varicose veins

Varicose vein procedure

 

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

0584T

 

Transplant Surgeries

Organ/Tissue Transplant - Islet Cell (pancreas)

 

Yes

No

0585T

 

Transplant Surgeries

Organ/Tissue Transplant - Islet Cell (pancreas)

 

Yes

No

0586T

 

Transplant Surgeries

Organ/Tissue Transplant - Islet Cell (pancreas)

 

Yes

No

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

0905

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

Yes

0906

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

Yes

0912

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

Yes

0913

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

Yes

10040

 

Reconstructive or Cosmetic services: Acne Surgery

Surgery - skin Procedure

 

Yes

Yes

11000

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

11001

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

11042

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

11043

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

11044

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

11750

 

Office Surgical Procedures

Nail Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

11765

 

Office Surgical Procedures

Nail Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

11920

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

11921

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth 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

Preauth not required for treatment of cancer.

Yes

Yes

11971

 

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Preauth not required for treatment of cancer.

Yes

Yes

12001

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

12011

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only when performed in a facility.

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

Yes

15273

 

Other services: wound care products

Wound care

 

Yes

Yes

15275

 

Other services: wound care products

Wound care

 

Yes

Yes

15277

 

Other services: wound care products

Wound care

 

Yes

Yes

15771

 

Reconstructive or Cosmetic services: Breast Procedures

Reconstructive or Cosmetic services: Augmentation and Grafting

 

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

Yes

15781

 

Reconstructive or Cosmetic services: Dermabrasion

Skin Procedure

 

Yes

Yes

15782

 

Reconstructive or Cosmetic services: Dermabrasion

Skin Procedure

 

Yes

Yes

15783

 

Reconstructive or Cosmetic services: Dermabrasion

Skin Procedure

 

Yes

Yes

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

Yes

15821

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

15822

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

15823

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

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

Yes

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

Yes

15878

 

Reconstructive or Cosmetic services: Excision /Lipectomy

Skin Procedure

 

Yes

Yes

15879

 

Reconstructive or Cosmetic services: Excision /Lipectomy

Skin Procedure

 

Yes

Yes

16000

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only performed in a facility.

Yes

Yes

16020

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only performed in a facility.

Yes

Yes

16025

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only performed in a facility.

Yes

Yes

16030

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only performed in a facility.

Yes

Yes

16035

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only performed in a facility.

Yes

Yes

16036

 

Office Surgical Procedures

Skin Procedure

Requires preauthorization only performed in a facility.

Yes

Yes

17106

 

Other services: Laser treatment

Skin Procedure

 

Yes

Yes

17107

 

Other services: Laser treatment

Skin Procedure

 

Yes

Yes

17108

 

Other services: Laser treatment

Skin Procedure

 

Yes

Yes

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

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

19297

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

19298

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

19300

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19316

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19318

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19324

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19325

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19328

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19330

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19340

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19342

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19350

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19355

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19357

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19361

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19364

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19366

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19367

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19368

Reconstructive or Cosmetic services: Breast Procedures

 

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19369

Reconstructive or Cosmetic services: Breast Procedures

 

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19370

Reconstructive or Cosmetic services: Breast Procedures

 

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19371

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19380

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

19396

 

Reconstructive or Cosmetic services: Breast Procedures

Surgery - Breast

Preauth not required for treatment of cancer.

Yes

Yes

20550

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

20551

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

20552

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

20553

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

20600

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

20605

 

ffice Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

20610

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

20612

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

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

20983

 

Outpatient Surgery for Select Procedures

Tumor Ablations

 

Yes

Yes

21073

 

Investigational and Experimental Procedures

Investigational TMJ treatment

 

Yes

Yes

21116

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

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

Yes

21242

 

Reconstructive or Cosmetic services: Augmentation and Grafting

Surgery - Head/Face

 

Yes

Yes

21243

 

Reconstructive or Cosmetic services: Augmentation and Grafting

Surgery - Head/Face

 

Yes

Yes

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

21260

 

 

Reconstructive or Cosmetic services: Augmentation and Grafting

Surgery - Head/Face

 

Yes

Yes

21261

 

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

This service is preauthorized through Turning Point

Yes

Yes

22222

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22224

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22226

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22510

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22511

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22512

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22513

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22514

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22515

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22532

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22533

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22534

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22548

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22551

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22552

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22554

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22556

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22558

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22585

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22586

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22590

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22595

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22600

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22610

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22612

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22614

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22630

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22632

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22633

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22634

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22800

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22802

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22804

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22808

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22810

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22812

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22818

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22819

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22830

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22849

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22856

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22857

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22858

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22861

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22862

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22864

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22865

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22867

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22868

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22869

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22870

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22899

 

Surgery for Select Procedures

Musculoskeletal Procedures

This service is preauthorized through Turning Point

Yes

Yes

23120

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point.

Yes

Yes

23125

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23130

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23190

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23195

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23333

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23334

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23335

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23395

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23397

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23400

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23405

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23406

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23410

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23412

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23415

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23420

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23440

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23450

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23455

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23460

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23462

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23465

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23466

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23470

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23472

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23473

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23474

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23616

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23800

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

23802

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27033

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27090

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27091

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27120

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27122

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27125

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27130

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27132

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27134

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27137

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27138

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27146

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27147

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27151

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27156

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27158

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27161

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27236

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27279

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27280

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27284

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27286

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27299

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27403

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27405

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27407

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27409

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27412

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27415

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27416

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27418

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27420

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27422

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27424

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27425

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27427

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27428

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27429

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27437

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27438

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27440

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27441

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27442

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27443

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27445

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27446

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27447

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27486

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27487

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27488

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27570

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

27580

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

28446

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29827

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29850

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29851

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29855

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29856

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29860

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29861

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29862

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29863

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29866

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29867

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29868

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29870

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29871

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29873

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29874

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29875

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29876

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29877

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29879

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29880

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29881

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29882

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29883

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29884

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29885

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29886

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29887

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29888

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29889

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29914

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29915

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29916

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

29999

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point.

Yes

Yes

30400

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30410

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30420

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30430

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30435

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30450

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30460

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30462

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

30520

 

Reconstructive or Cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

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 Pre-Auth.  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 Pre-Auth.  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 Pre-Auth.  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

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

33270

 

Investigational and Experimental Procedures

Investigational heart procedures

 

Yes

Yes

33271

 

Investigational and Experimental Procedures

Investigational heart procedures

 

Yes

Yes

33273

 

Investigational and Experimental Procedures

Investigational heart procedures

 

Yes

Yes

33285

 

Outpatient Surgery: Elective Cardiac Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

33361

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

Yes

33362

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

Yes

33363

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

Yes

33364

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

Yes

33365

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

Yes

33366

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

Yes

33418

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

No

33419

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

No

33477

 

Outpatient Surgery for Select Procedures

Surgery - Heart valve

 

Yes

No

33622

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

33927

 

Transplant Surgeries

Organ/Tissue Transplant - Heart

 

Yes

No

33928

 

Transplant Surgeries

Organ/Tissue Transplant - Heart

 

Yes

No

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

Yes

33980

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

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

34501

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

34502

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

34510

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

34520

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

34530

 

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

36465

 

Reconstructive or Cosmetic services: Varicose veins

Varicose vein procedure

 

Yes

Yes

36466

 

Reconstructive or Cosmetic services: Varicose veins

Varicose vein procedure

 

Yes

Yes

36468

 

Reconstructive or Cosmetic services: Varicose veins

Vein Procedures

 

Yes

No

36470

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

36471

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

36475

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

36478

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

36482

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

37216

 

Investigational and Experimental Procedures

Investigational and Experimental Procedures

 

No

Yes

37241

 

Outpatient Surgery for Select Procedures

Surgery - Heart/Blood Vessel

 

Yes

Yes

37500

 

Reconstructive or Cosmetic services: Varicose veins

Vein Procedures

 

Yes

Yes

37700

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37718

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37722

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37735

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37760

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37761

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37765

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37766

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37780

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

37785

 

Reconstructive or Cosmetic services: Varicose veins

Surgery - Varicose Vein

 

Yes

Yes

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

Yes

38208

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38209

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38210

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38211

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38212

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38213

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38214

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38215

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

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

Yes

38241

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38242

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

38243

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

41822

 

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

Yes

41823

 

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

Yes

41825

 

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

Yes

41826

 

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

Yes

41850

 

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

Yes

43229

 

Outpatient Surgery for Select Procedures

Gastrointestinal Procedure

Requires Preauth only for treatment of Barrett’s esophagus with dysplasia

Yes

No

43270

 

Outpatient Surgery for Select Procedures

Gastrointestinal Procedure

Requires Preauth only for treatment of Barrett’s esophagus with dysplasia

Yes

No

43644

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43645

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43659

 

Outpatient Surgery for Select Procedures

Surgery - Stomach and Intestines

 

Yes

Yes

43770

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43771

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43772

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43773

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43774

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43775

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43842

 

Investigational and Experimental Procedures

Investigational Weight Loss Surgery

 

Yes

Yes

43843

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43845

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43846

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43847

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43848

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43886

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43887

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

43888

 

Outpatientservices: Bariatric Surgery

Surgery - Weight Loss

 

Yes

Yes

44132

 

Transplant Surgeries

Organ/Tissue Transplant - Intestine

 

Yes

Yes

44133

 

Transplant Surgeries

Organ/Tissue Transplant - Intestine

 

Yes

Yes

44135

 

Transplant Surgeries

Organ/Tissue Transplant - Intestine

 

Yes

Yes

44136

 

Transplant Surgeries

Organ/Tissue Transplant - Intestine

 

Yes

Yes

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

45300

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45303

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45305

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45307

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45308

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45309

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45315

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45317

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45320

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

45321

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

46230

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

46320

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

46924

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

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

Yes

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

50542

 

Outpatient Surgery for Select Procedures

Tumor Ablations

 

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

54065

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

55250

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

56820

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

56821

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

57420

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

57421

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

57452

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

57454

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

57455

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

57456

 

Office Surgical Procedures

Genital/Reproductive Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

61630

 

Investigational and Experimental Procedures

Investigational heart procedures

Non Covered for Commercial Product

No

Yes

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

No

61886

 

Outpatient Surgery for Select Procedures

Nerve Stimulator

 

Yes

No

61888

 

Outpatient Surgery for Select Procedures

Nerve Stimulator

 

Yes

No

62287

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63001

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63003

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63005

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63011

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63012

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63015

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63016

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63017

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63020

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63030

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63035

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63040

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63042

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63043

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63044

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63045

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63046

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63047

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63048

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63050

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63051

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63055

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63056

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63057

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63064

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63066

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63075

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63076

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63077

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63078

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63081

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63082

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63085

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63086

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63087

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63088

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63090

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63091

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63101

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63102

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63103

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63170

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63172

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63173

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63180

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63182

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63185

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63190

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63191

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63194

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63195

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63196

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63197

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63198

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63199

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63200

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63250

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63251

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63252

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63265

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63266

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63267

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63268

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63270

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63271

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63272

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63273

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63275

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63276

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63277

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63278

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63280

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63281

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63282

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63283

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63285

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63286

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63287

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63290

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63295

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63300

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63301

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63302

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63303

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63304

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63305

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63306

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63307

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

63308

 

Surgery for Select Procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

64420

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

64421

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

64450

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

64451

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

64454

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

64553

 

Outpatient Surgery for Select Procedures

Nerve Stimulator

 

Yes

Yes

64555

 

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

64575

 

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

64585

 

Outpatient Surgery for Select Procedures

Nerve Stimulator

 

Yes

Yes

64590

 

Outpatient Surgery for Select Procedures

Nerve Stimulator

 

Yes

Yes

64595

 

Outpatient Surgery for Select Procedures

Nerve Stimulator

 

Yes

Yes

64620

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

64624

 

Office Surgical Procedures

Office Surgical Procedures

Requires preauthorization only when performed in a facility.

Yes

Yes

64633

 

Investigational and Experimental Procedures

Investigational Nerve Procedure

 

Yes

Yes

64635

 

Outpatient Surgery for Select Procedures

Nerve Procedures

 

Yes

Yes

64640

 

Office Surgical Procedures

Injection Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

65756

 

Outpatient Surgery for Select Procedures

Surgery - Eye

 

Yes

Yes

65778

 

Outpatient Surgery for Select Procedures

Surgery - Eye

 

Yes

Yes

65779

 

Outpatient Surgery for Select Procedures

Surgery - Eye

 

Yes

Yes

65780

 

Outpatient Surgery for Select Procedures

Surgery - Eye

 

Yes

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

67800

 

Office Surgical Procedures

Surgery - Eyelid

Requires preauthorization only when performed in a facility.

Yes

Yes

67801

 

Office Surgical Procedures

Surgery - Eyelid

Requires preauthorization only when performed in a facility.

Yes

Yes

67805

 

Office Surgical Procedures

Surgery - Eyelid

Requires preauthorization only when performed in a facility.

Yes

Yes

67900

 

Reconstructive or Cosmetic services: PtoSIS repair

 

Surgery - Eyelid

 

Yes

Yes

67901

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

67902

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

67903

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

67904

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

67906

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

67908

 

Reconstructive or Cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

Yes

67909

 

Reconstructive or Cosmetic services: PtoSIS repair

 

Surgery - Eyelid

 

Yes

Yes

67911

 

Reconstructive or Cosmetic services: PtoSIS repair

 

Surgery - Eyelid

 

Yes

Yes

68371

 

Transplant Surgeries

Organ/Tissue Transplant - Conjunctiva (eye)

 

 

Yes

Yes

69300

 

Reconstructive or Cosmetic services: Otoplasty

Surgery - Head/Face

 

Yes

Yes

69710

 

Outpatient Surgery for Select Procedures

Hearing testing and treatment

 

Yes

No

69711

 

Outpatient Surgery for Select Procedures

Hearing testing and treatment

 

Yes

Yes

69714

 

Outpatient Surgery for Select Procedures

Hearing testing and treatment

 

Yes

Yes

69715

 

Outpatient Surgery for Select Procedures

Hearing testing and treatment

 

Yes

Yes

69717

 

Outpatient Surgery for Select Procedures

Hearing testing and treatment

 

Yes

Yes

69718

 

Outpatient Surgery for Select Procedures

Hearing testing and treatment

 

Yes

Yes

69930

 

Outpatient Surgery for Select Procedures

Hearing testing and treatment

 

Yes

Yes

70336

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70450

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70460

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70470

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70480

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70481

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70482

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70486

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70487

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70488

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70490

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70491

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70492

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70496

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70498

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70540

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70542

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70543

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70544

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70545

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70546

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70547

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70548

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70549

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70551

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70552

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70553

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70554

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

70555

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71250

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71260

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71270

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71275

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71550

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71551

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71552

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

71555

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72125

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72126

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72127

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72128

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72129

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72130

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72131

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72132

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72133

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72141

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72142

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72146

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72147

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72148

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72149

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72156

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72157

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72158

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72159

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72191

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72192

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72193

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72194

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72195

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72196

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72197

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

72198

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73200

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73201

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73202

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73206

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73218

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73219

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73220

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73221

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73222

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73223

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73225

 

Diagnostic Services: MRI

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73700

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73701

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73702

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73706

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73718

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73719

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73720

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73721

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73722

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73723

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

73725

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74150

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74160

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74170

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74174

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74175

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74176

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74177

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74178

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74181

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74182

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74183

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74185

 

Diagnostic Services: MRI

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74261

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74262

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74263

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

No

74712

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

74713

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75557

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75559

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75561

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75563

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75565

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75571

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75572

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75573

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

75635

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

76380

 

Diagnostic Services: CT Scans

X-Ray/Imaging - Cat Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

76390

 

Diagnostic Services: SPECT

Nuclear medicine testing - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

77014

 

Therapy services: Radiation therapy , IGRT

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

77046

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

77047

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

77048

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

77049

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

77084

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

77280

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77285

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77290

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77295

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77300

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77301

 

Reconstructive or Cosmetic services: Breast Procedures

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77306

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77307

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77316

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77317

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77318

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77321

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77331

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77332

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77333

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77334

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77336

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77338

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77370

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77371

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77372

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77373

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77385

 

Therapy services: Radiation therapy , IMRT

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77386

 

Therapy services: Radiation therapy , IMRT

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77387

 

Therapy services: Radiation therapy , IGRT

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77399

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77401

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77402

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77407

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77412

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77417

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77423

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77424

 

Therapy services: Radiation therapy ,IORT

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77425

 

Therapy services: Radiation therapy ,IORT

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77427

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77431

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77432

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77435

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77469

 

Therapy services: Radiation therapy ,IORT

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77470

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77499

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77520

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77522

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77523

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77525

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77600

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77605

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77610

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77615

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77620

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77761

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77762

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77763

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77767

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77768

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77770

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77771

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77772

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77778

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77789

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77790

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

77799

 

Therapy services: Radiation therapy

Radiation therapy

This service is preauthorized through National Imaging Associates (NIA).

Yes

Yes

78429

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78430

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78431

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78432

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78433

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78434

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78451

 

Diagnostic Services: SPECT

X-Ray/Imaging -SPECT

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78452

 

Diagnostic Services: SPECT

X-Ray/Imaging -SPECT

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78453

 

Diagnostic Services: Cardiac Nuclear Medicine Studies

X-Ray/Imaging - Cardiac Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78454

 

Diagnostic Services: Cardiac Nuclear Medicine Studies

X-Ray/Imaging - Cardiac Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78459

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78466

 

Diagnostic Services: Cardiac Nuclear Medicine Studies

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78468

 

Diagnostic Services: Cardiac Nuclear Medicine Studies

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78469

 

Outpatient Surgery: Elective Cardiac Procedures

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78472

 

Diagnostic Services: MUGA

Nuclear medicine testing - heart

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78473

 

Diagnostic Services: MUGA

Nuclear medicine testing - heart

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78481

 

Outpatient Surgery: Elective Cardiac Procedures

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78483

 

Outpatient Surgery: Elective Cardiac Procedures

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78491

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78492

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78494

 

Diagnostic Services: MUGA

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78496

 

Diagnostic Services: MUGA

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78499

 

Diagnostic Services: Cardiac Nuclear Medicine Studies

X-Ray/Imaging - Heart Studies

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78608

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78609

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78803

 

Diagnostic Services:

X-Ray/Imaging -SPECT

 

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78811

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78812

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

78813

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78814

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78815

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

78816

 

Diagnostic Services: PET Scans

X-Ray/Imaging - PET Scan

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

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

Yes

81121

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81161

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81162

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81163

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81164

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81165

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81166

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81167

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81170

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81171

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

No

81172

 

Lab/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

Yes

81176

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

81200

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

81206

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81207

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81208

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81209

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81210

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81212

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81215

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81216

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81217

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

81218

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81219

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81220

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81221

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81222

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81223

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81224

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81225

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81226

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81228

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81229

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81230

 

Diagnostic Services: Genetic Testing

Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81231

 

Diagnostic Services: Genetic Testing

Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81232

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81233

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81234

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81235

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81236

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81237

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

81243

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81244

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81245

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81246

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81250

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81251

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81252

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81253

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81254

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81255

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81256

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81257

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81258

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81259

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81260

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81261

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81262

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81263

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81270

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81271

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81272

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81273

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81274

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81275

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81276

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81277

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81283

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

81287

 

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

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81292

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

81306

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

81311

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

 

Yes

Yes

81312

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81313

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81314

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81315

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81316

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

81325

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81326

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81327

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

 

Yes

Yes

81328

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81329

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81330

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

81335

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

Yes

81341

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81342

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

81346

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81350

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

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

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81401

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81402

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81403

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81404

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81405

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81406

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81407

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81408

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81410

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81411

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81412

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81413

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

 

Yes

Yes

81414

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

 

Yes

Yes

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

81420

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81422

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

 

Yes

Yes

81425

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81426

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81427

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81430

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81431

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81432

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81433

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81434

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81435

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81436

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81437

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81438

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81439

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

 

Yes

Yes

81440

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81442

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81443

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

No

81445

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81448

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81450

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81455

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81460

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81465

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81470

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81471

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81479

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81490

 

Investigational and Experimental Procedures

Investigational Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81493

 

Diagnostic Services: Genetic Testing

Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81507

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81518

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81519

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81520

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81521

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81522

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

81538

 

Diagnostic Services: Genetic Testing

Lab/Genetic Testing

5/1/2016 effective for Preauth.

Yes

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

No

Yes

81542

 

Lab/Genetic Testing

Lab/Genetic Testing

 

No

Yes

81545

 

Diagnostic Services: Genetic Testing

Lab/Genetic Testing

5/1/2016 effective for Preauth.

Yes

Yes

81551

 

Diagnostic Services: Genetic Testing

Lab/Genetic Testing

Non Covered for Commercial Product

No

Yes

81552

 

Lab/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

87900

 

Investigational and Experimental Procedures

LAB test

 

Yes

Yes

87901

 

Investigational and Experimental Procedures

LAB test

 

Yes

Yes

87903

 

Investigational and Experimental Procedures

LAB test

 

Yes

Yes

87906

 

Investigational and Experimental Procedures

LAB test

 

Yes

Yes

88240

 

Transplant Surgeries

Blood or Marrow Stem Cell Transplants

 

Yes

Yes

88245

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88248

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88249

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88261

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88262

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88263

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88264

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88267

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88269

 

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

88280

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88283

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88285

 

Lab/Genetic Testing

Lab/Genetic Testing

 

Yes

Yes

88289

 

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

 

Yes

No

90283

 

Medical injectables/other Non-injectable drugs

Medical specialty drug

 

Yes

No

90284

 

Medical injectables/other Non-injectable drugs

Medical specialty drug

 

Yes

No

90378

 

Medical injectables/other Non-injectable drugs

Medical specialty drug

 

Yes

No

90867

 

Select Outpatient Behavioral Health Services

Investigational Nerve Stimulator

This service is preauthorized through Magellan.

Yes

Yes

90868

 

Select Outpatient Behavioral Health Services

Investigational Nerve Stimulator

This service is preauthorized through Magellan.

Yes

Yes

90869

 

Select Outpatient Behavioral Health Services

Investigational Nerve Stimulator

This service is preauthorized through Magellan.

Yes

Yes

90997

 

Investigational and Experimental Procedures

Dialysis Procedure

 

Yes

Yes

93228

 

Investigational and Experimental Procedures

Investigational and Experimental Procedures

 

Yes

Yes

93229

 

Investigational and Experimental Procedures

Investigational and Experimental Procedures

 

Yes

Yes

93303

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93304

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93306

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93307

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93308

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93312

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93313

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93314

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93315

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93316

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93317

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93318

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93350

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93351

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93352

 

Diagnostic Services: Cardiac Testing

X-Ray/Imaging - Cardiac Studies

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

93668

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

95782

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95783

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95800

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95801

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95805

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95806

 

Other services: Sleep Studies Faciliy Based

Sleep studies

Preauth required when performed in a facility.

Yes

No

95807

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95808

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95810

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95811

 

Other services: Sleep Studies Faciliy Based

Sleep studies

 

Yes

No

95930

 

Investigational and Experimental Procedures

Brain testing

 

Yes

No

96567

 

Investigational and Experimental Procedures

Skin Procedure

 

Yes

No

96573

 

Investigational and Experimental Procedures

Investigational and Experimental Procedures

 

Yes

No

96574

 

Investigational and Experimental Procedures

Investigational and Experimental Procedures

 

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

97012

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97014

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

No

97016

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97018

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97022

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97024

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97028

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97032

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97033

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

No

97034

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97035

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97036

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97039

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97110

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97112

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97113

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97116

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97124

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97129

 

Therapy services: Occupational therapy

Therapy services: Occupational therapy

 

Yes

Yes

97130

 

Therapy services: Occupational therapy

Therapy services: Occupational therapy

 

Yes

Yes

97139

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97140

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97150

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97151

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

97153

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

97154

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

97155

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

97156

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

97157

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

97158

 

Select Outpatient Behavioral Health Services

Behavioral Health Service

This service is preauthorized through Magellan

Yes

No

97161

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97162

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97163

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97164

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97165

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97166

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97167

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97168

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97530

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97533

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97535

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97542

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97750

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97755

 

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

97760

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97761

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97763

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

97799

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

99170

 

Office Surgical Procedures

Gastrointestinal Procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

99183

 

Therapy services: Hyperbaric Oxygen

Hyperbaric Oxygen

 

Yes

Yes

99375

 

Other services: Home Health Care

Home health care

 

Yes

No

99500

 

Other services: Home Health Care

Home health care

 

Yes

No

99501

 

Other services: Home Health Care

Home health care

 

Yes

No

99502

 

Other services: Home Health Care

Home health care

 

Yes

No

99503

 

Other services: Home Health Care

Home health care

 

Yes

No

99504

 

Other services: Home Health Care

Home health care

 

Yes

No

99505

 

Other services: Home Health Care

Home health care

 

Yes

No

99506

 

Other services: Home Health Care

Home health care

 

Yes

No

99507

 

Other services: Home Health Care

Home health care

 

Yes

No

99509

 

Other services: Home Health Care

Home health care

 

Yes

No

99511

 

Other services: Home Health Care

Home health care

 

Yes

No

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

A4290

Sacral Nerve stimulation test lead, each

Investigational and Experimental Procedures

Nerve Stimulator

 

Yes

Yes

A9274

External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories

Diabetic DME & supplies

DME Supplies

 

Yes

No

A9276

Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continious glucose monitoring system, 1 unit = 1 day Supply

Diabetic DME & supplies

Diabetic Supplies

 

Yes

No

A9277

Transmitter; external, for use with interstitial continious glucose monitoring system

Diabetic DME & supplies

Diabetic Supplies

 

Yes

No

A9278

Receiver (monitor); external, for use with interstitial continious 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 Prime Therapeutics LLC for BlueJourney

No

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

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: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

B9002

Enternal nutrition infusion pump - any type

Other services: enternal feeding and supplies

Special nutrient formula

 

Yes

Yes

B9998

NoC for enteral supplies

Other services: enternal feeding and supplies

DME Supplies

 

Yes

Yes

C1764

Event recorder, cardiac (implantable)

DME: implant

DME Implant

 

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

C1778

Lead, neurostimulator (implantable)

DME: prosthetic appliances and implants

Nerve Stimulator

Facility code requires preauthorization

Yes

Yes

C1783

Ocular implant, aqueous drainage assist device

DME: prosthetic appliances and implants

Prosthetic devices

Facility code requires preauthorization

Yes

Yes

C1787

Patient programmer neurostimilator

DME: prosthetic appliances and implants

Nerve Stimulator

Facility code requires preauthorization

Yes

Yes

C1820

Generator, neurostimulator (implantable), with rechargeabe 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

This service is preauthorized through Turning Point

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

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

C1897

Lead, neurostimulator test kit (implantable)

DME: prosthetic appliances and implants

Nerve Stimulator

Facility code requires preauthorization

Yes

Yes

C2616

Brachytherapy source, nonstranded, YTTRIUM-90, per source

Therapy services: Radiation therapy

Radiation therapy

Facility code requires preauthorization. This service is preauthorized through National Imaging Associates (NIA). *Traditional Products do not require Preauth

Yes

Yes

C2626

Infusion pump, Nonprogrammable, temporary (implantable)

DME: implant

DME Pump

Facility code requires preauthorization

Yes

Yes

C5271

Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C5272

Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separrately in addition to code for primary Procedure)

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C5273

Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C5274

Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C5275

Application of low cost skin substitute graft to face, scalp, Eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

 

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C5276

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C5277

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C5278

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)

Other services: Bio-Engineered skin or Biological wound care

Skin Procedure

Facility code requires preauthorization

Yes

Yes

C8900

Magnetic Resonance Angiography with contrast, abdomen

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8901

Magnetic Resonance Angiography without contrast, abdomen

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8902

Magnetic Resonance Angiography without contrast followed by with contrast, abdomen

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8903

Magnetic Resonance imaging with contrast, breast; unilateral

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8905

Magnetic Resonance imaging without contrast, breast; unilateral

 

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8906

Magnetic Resonance imaging with contrast, breast; bilateral

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8908

Magnetic Resonance imaging without contrast followed by with contrast, breast; bilateral

Diagnostic Services: MRI

X-Ray/Imaging - MRI

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8909

Magnetic Resonance Angiography with contrast, Chest (excluding myocardium)

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8910

Magnetic Resonance Angiography without contrast, Chest (excluding myocardium)

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8911

Magnetic Resonance Angiography without contrast followed by with contrast, Chest (excluding myocardium)

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8912

Magnetic Resonance Angiography with contrast, lower extremity

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8913

Magnetic Resonance Angiography without contrast, lower extremity

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8914

Magnetic Resonance Angiography without contrast followed by with contrast, lower extremity

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -'Traditional Products do not require Preauth

Yes

Yes

C8918

Magnetic Resonance Angiography with contrast, pelvis

 

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

C8919

Magnetic Resonance Angiography without contrast, pelvis

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

C8920

Magnetic Resonance Angiography without contrast followed by with contrast, pelvis

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

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

"This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth 1 Applies to Fully Insured Products"

Yes

Yes

C8931

Magnetic Resonance Angiography with contrast, spinal canal and contents

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

C8932

Magnetic resonance angiography without contrast, spinal canal and contents

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

C8933

Magnetic Resonance Angiography without contrast followed by with contrast, spinal canal and contents

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

C8934

Magnetic Resonance Angiography with contrast, upper extremity

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

C8935

Magnetic Resonance Angiography without contrast, upper extremity

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require Preauth

Yes

Yes

C8936

Magnetic Resonance Angiography without contrast followed by with contrast, upper extremity

Diagnostic Services: MRA

X-Ray/Imaging - MRA

This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require Preauth

Yes

Yes

C9061

Injection, teprotumumab-trbw, 10 mg

Medical injectables/other Non-injectable drugs

Medical specialty drug

 

Yes

No

C9064

Mitomycin pyelocalyceal instillation, 1 mg

Medical injectables/other Non-injectable drugs

Injection Procedure

This service is preauthorized by Capital BlueCross for Commercial and Blue Journey.  Claims should be submitted with National Drug Code (NDC) and supporting documentation.  Jelmyto (C9064) requires PREAUTH only for this specialty injectable

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

This service is preauthorized through Turning Point

Yes

Yes

C9761

Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with lithotripsy (ureteral catheterization is included) and vacuum aspiration of the kidney, collecting system and urethra if applicable.

Outpatient Surgery for Select Procedures

Surgery - Stomach and Intestines

 

Yes

Yes

C9763

Cardiac Magnetic Resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging

Diagnostic Services: MRI

Diagnostic Services : MRI

 

Yes

Yes

C9769

Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts.

Surgery for Select Procedures

Prosthetic Devices

 

Yes

Yes

D0470

Diagnostic casts; also known as diagnostic models or study models.

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

No

D7210

Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated; includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure.

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7220

Removal of impacted tooth - soft tissue

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7230

Removal of impacted tooth - partially bony; part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7240

Removal of impacted tooth - completely bony; most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7241

Removal of impacted tooth - completely bony, with unusual surgical complications; most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7250

Removal of residual tooth roots (cutting procedure); includes cutting of soft tissue and bone, removal of tooth structure, and closure

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7270

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth; includes splinting and/or stabilization

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7285

Incisional biopsy of oral tissue-hard (bone, tooth); for partial removal of specimen only. this procedure involves biopsy of osseous lesions and is not used for apicoectomy/periradicular surgery. this procedure does not entail an excision.

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7286

Incisional biopsy of oral tissue-soft; for partial removal of an architecturally intact specimen only. this procedure is not used at the same time as codes for apicoectomy/periradicular curettage. this procedure does not entail an excision

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7410

Excision of benign lesion up to 1.25 CM

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7413

Excision of malignant lesion up to 1.25 CM

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7440

Excision of malignant Tumor - lesion diameter up to 1.25 CM

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7450

Removal of benign odontogenic cyst or Tumor- lesion diameter up to 1.25 CM

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7460

Removal of benign nonodontogenic cyst or Tumor-lesion diameter up to 1.25 CM

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7465

Destruction of lesion(s) by physical or chemical method, by report; examples include using cryo, laser or electro surgery

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7471

Removal of lateral exostosis (maxilla or mandible)

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7472

Removal of torus palatinus

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7473

Removal of torus mandibularis

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7510

Incision and drainage of abscess - intraoral soft tissue; involves incision through mucosa, including periodontal origins

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7520

Incision and drainage of abscess - extraoral soft tissue; involves incision through skin

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7530

Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7540

Removal of reaction producing foreign bodies, musculoskeletal system; may include, but is not limited to, removal of splinters, pieces of wire, etc., from muscle and/or bone

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7620

Maxilla - closed reduction (teeth immobilized, if present); no incision required to reduce fracture. see d7610 if interosseous fixation is applied

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7640

Mandible - closed reduction (teeth immobilized, if present); no incision required to reduce fracture. see d7630 if interosseous fixation is applied

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7720

Maxilla - closed reduction

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7740

Mandible - closed reduction

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

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

Yes

D7870

Arthrocentesis; withdrawal of fluid from a joint space by aspiration

Office Surgical Procedures

Dental Procedures

Requires preauthorization only performed in a facility.

Yes

Yes

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

D7946

Lefort I (maxilla - total); sectioning of the upper jaw. This includes exposure, bone cuts, downfracture, repositioning, fixation, routine wound closure and normal post-operative follow-up care

Reconstructive or Cosmetic services: Augmentation and Grafting

Surgery - Head/Face

 

Yes

Yes

D7947

Lefort I (maxilla - segmented); when reporting a surgically assisted palatal expansion without downfracture, this code would entail a reduced service and should be "by report"

Reconstructive or Cosmetic services: Augmentation and Grafting

Surgery - Head/Face

 

Yes

Yes

D7948

Lefort II or Lefort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft; sectioning of upper jaw. this includes exposure, bone cuts, downfracture, segmentation of maxilla, repositioning, fixation, routine wound closure and normal post-operative follow-up care

Reconstructive or Cosmetic services: Augmentation and Grafting

Surgery - Head/Face

 

Yes

Yes

D7949

Lefort II or Lefort III - with bone graft; includes obtaining autografts

Reconstructive or Cosmetic services: Augmentation and Grafting

Surgery - Head/Face

 

Yes

Yes

D9942

Repair and/or reline of Occlusal GUARD

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

No

D9950

Occlusion analysis - mounted case; includes, but is not limited to, facebow, interocclusal records tracings, and diagnostic wax-up; for diagnostic casts, SEE D0470.

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

No

D9951

Occlusal adjustment - limited; may also be known as equilibration; reshaping the occlusal surfaces of teeth to create harmonious contact relationships between the maxillary and mandibular teeth. presently includes discing/odontoplasty/enamoplasty. typically reported on a "per visit" basis. this should not be reported when the procedure only involves bite adjustment in the routine post-delivery care for a direct/indirect restoration or fixed/removable prosthodontics

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

No

D9952

Occlusal adjustment - complete; occlusal adjustment may require several appointments of varying length, and sedation may be necessary to attain adequate relaxation of the musculature. study casts mounted on an articulating instrument may be utilized for analysis of occlusal disharmony. it is designed to achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontics, orthognathic surgery, or jaw trauma when indicated. occlusal adjustment enhances the healing potential of tissues affected by the lesions of occlusal trauma

Office Surgical Procedures

Dental Procedures

Requires preauthorization only when performed in a facility.

Yes

No

E0193

Powered air flotation bed (low air Loss therapy )

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0194

Air fluidized bed

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0250

Hospital bed, fixed height, with any type side rails, with mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0251

Hospital bed, fixed height, with any type side rails, without mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0255

Hospital bed, variable height, HI-LO, with any type side rails, with mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0256

Hospital bed, variable height, HI-LO, with any type side rails, without mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0260

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0261

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

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

Yes

E0290

Hospital bed, fixed height, without side rails, with mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0291

Hospital bed, fixed height, without side rails, without mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0292

Hospital bed, variable height, HI-LO, without side rails, with mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0293

Hospital bed, variable height, HI-LO, without side rails, without mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0294

Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

E0295

Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress

DME: hospital beds & supplies

Hospital Bed

 

Yes

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

Yes

E0562

Humidifier, heated, used with positive airway pressure device

DME: ventilators & airway assist devices

DME: C-PAP & supplies

 

Yes

Yes

E0601

Continuous positive airway pressure (CPAP) device

DME: ventilators & airway assist devices

DME: C-PAP & supplies

 

Yes

Yes

E0616

Implantable cardiac event recorder with memory, activator, and programmer

DME: implant

DME Device

 

Yes

Yes

E0617

External defibrillator with integrated electrocardiogram analysis

Defibrillator & supplies

DME Supplies

 

Yes

Yes

E0636

Multipositional patient support system, with integrated lift, patient accessible controls

DME: patient lifts

DME Supplies

 

Yes

Yes

E0650

Pneumatic compressor, nonsegmental home model

DME: compression devices

DME Supplies

 

Yes

Yes

E0651

Pneumatic compressor, segemental home model without calibrated gradient pressure

DME: compression devices

DME Supplies

 

Yes

Yes

E0652

Pneumatic compressor, segemental home model with calibrated gradient pressure

DME: compression devices

DME Supplies

 

Yes

Yes

E0655

Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm

DME: compression devices

DME Supplies

 

Yes

Yes

E0660

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

DME: compression devices

DME Supplies

 

Yes

Yes

E0665

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

DME: compression devices

DME Supplies

 

Yes

Yes

E0666

Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

DME: compression devices

DME Supplies

 

Yes

Yes

E0667

Segemental pneumatic appliance for use with pneumatic compressor, full leg

DME: compression devices