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 Blue Cross' 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 Blue Cross and is to be used only for its intended purposes.

Do not disclose

CPT and revenue code descriptions are subject to copyright and therefore not included on the external single source preauthorization code list. 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 Blue Cross 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 Blue Cross 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 Blue Cross 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.

Code	HCPCS and dental code description	Preauthorization category	Type of care	Comments	Commercial	BlueJourney
0901		Select outpatient behavioral health services	Behavioral health service	Facility revenue code requires preauthorzation	Yes	Yes
0944		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	No	Yes
0945		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	No	Yes
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 preauthorization	Yes	Yes
0046U		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
0047U		Diagnostic services: Genetic testing	Investigational lab/Genetic testing	Non covered for commercial product	Yes	Yes
0049U		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
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 our musculoskeletal services provider	Yes	Yes
0165T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	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 our musculoskeletal services provider	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 our musculoskeletal services provider	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 our musculoskeletal services provider	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 our musculoskeletal services provider	Yes	Yes
0220T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0221T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0222T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0230U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0231U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0232U		Diagnostic services: Genetic testing	Lab/Genetic testing	If it does not meet the medcially necessary critreia on policy then invalid	Yes	Yes
0233U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0234U		Diagnostic services: Genetic testing	Lab/Genetic testing	If it does not meet the criteria on 2.326	Yes	Yes
0235U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0236U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
0237U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0238U		Diagnostic services: Genetic testing	Lab/Genetic testing	If it does not meet criteria on policy then invalid	Yes	No
0239U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0250U		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
0252U		Diagnostic services: Genetic testing	Diagnostic services: Genetic testing		Yes	Yes
0258U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0260U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0264U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0265U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0266U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0267U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0268U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0269U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0270U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0271U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0272U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0273U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0274U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0276U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0277U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0278U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0282U		Diagnostic services: Genetic testing	Lab/genetic testing		Yes	Yes
0253T		Outpatient surgery for select procedures	Surgery - Eye		Yes	Yes
0274T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
0275T		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	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 Beacon Health.	Yes	No
0373T		Investigational and experimental procedures	Behavioral health service	This service is preauthorized through Beacon Health.	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 Beacon Health.	Yes	Yes
0906		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	Yes	Yes
0912		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	Yes	Yes
0913		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	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	Preauthorization not required for treatment of cancer.	Yes	Yes
11921		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
11950		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11951		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11952		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11954		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11960		Other services: Bio-engineered skin or biological wound care	Skin procedure		Yes	Yes
11970		Other services: Bio-engineered skin or biological wound care	Skin procedure	Preauthorization not required for treatment of cancer.	Yes	Yes
11971		Other services: Bio-engineered skin or biological wound care	Skin procedure	Preauthorization not required for treatment of cancer.	Yes	Yes
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	No
15823		Reconstructive or cosmetic services: Blepharoplasty	Surgery - Eyelid		Yes	No
15824		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15825		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15826		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15828		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15829		Reconstructive or cosmetic services: Rhytidectomy	Skin procedure		Yes	Yes
15830		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	No
15832		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15833		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15834		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15835		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15836		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15837		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15838		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15839		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15876		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	Yes
15877		Reconstructive or cosmetic services: Excision /Lipectomy	Skin procedure		Yes	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	Preauthorization not required for treatment of cancer.	Yes	Yes
19316		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19318		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19325		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19328		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19330		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19340		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19342		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19350		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19355		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19357		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19361		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19364		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19367		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19368		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19369		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19370		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19371		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19380		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	Yes
19396		Reconstructive or cosmetic services: Breast procedures	Surgery - Breast	Preauthorization not required for treatment of cancer.	Yes	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	No
20553		Office surgical procedures	Injection procedure	Requires preauthorization only when performed in a facility.	Yes	No
20600		Office surgical procedures	Injection procedure	Requires preauthorization only when performed in a facility.	Yes	Yes
20605		Office 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 our musculoskeletal services provider	Yes	Yes
22222		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22224		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22226		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22510		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22511		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22512		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22513		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22514		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22515		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22532		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22533		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22534		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22548		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22551		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22552		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22554		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22556		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22558		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22585		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22586		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22590		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22595		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22600		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22610		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22612		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22614		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22630		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22632		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22633		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22634		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22800		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22802		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22804		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22808		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22810		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22812		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22818		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22819		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22830		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22849		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22856		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22857		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22858		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22861		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22862		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22864		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22865		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22867		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22868		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22869		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22870		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
22899		Surgery for select procedures	Musculoskeletal Procedures	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23120		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider.	Yes	Yes
23125		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23130		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23190		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23195		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23333		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23334		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23335		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23395		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23397		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23400		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23405		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23406		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23410		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23412		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23415		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23420		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23440		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23450		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23455		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23460		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23462		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23465		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23466		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23470		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23472		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23473		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23474		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23616		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23800		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
23802		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27033		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27090		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27091		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27120		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27122		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27125		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27130		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27132		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27134		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27137		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27138		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27146		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27147		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27151		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27156		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27158		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27161		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27236		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27279		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27280		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27284		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27286		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27299		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27403		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27405		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27407		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27409		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27412		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27415		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27416		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27418		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27420		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27422		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27424		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27425		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27427		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27428		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27429		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27437		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27438		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27440		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27441		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27442		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27443		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27445		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27446		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27447		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27486		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27487		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27488		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27570		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
27580		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
28446		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29827		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29850		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29851		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29855		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29856		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29860		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29861		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29862		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29863		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29866		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29867		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29868		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29870		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29871		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29873		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29874		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29875		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29876		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29877		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29879		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29880		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29881		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29882		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29883		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29884		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29885		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29886		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29887		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29888		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29889		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29914		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29915		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29916		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
29999		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider.	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	No
30420		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30430		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30435		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30450		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	No
30460		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	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 preauthorization . MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018	Yes	Yes
31296		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses	11/16/2020 - Changing from non-covered to preauthorization . MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018	Yes	Yes
31297		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses	11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018	Yes	Yes
31298		Reconstructive or cosmetic services: repair nasal/septal defects	Surgery - nose/sinuses		Yes	Yes
31574		Reconstructive	Injection procedure		Yes	Yes
31591		Investigational and experimental procedures	Reconstructive or cosmetic services		Yes	Yes
31660		Surgery for select procedures	Surgery - Lung		Yes	Yes
31661		Surgery for select procedures	Surgery - Lung		Yes	Yes
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	Yes
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	No
38208		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38209		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38210		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38211		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38212		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38213		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38214		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38215		Transplant surgeries	Blood or marrow stem cell transplants		Yes	No
38230		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
38232		Transplant surgeries	Blood or marrow stem cell transplants		Yes	Yes
38240		Transplant surgeries	Blood or marrow stem cell transplants		Yes	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 preauthorization only for treatment of Barrett’s esophagus with dysplasia	Yes	No
43270		Outpatient surgery for select procedures	Gastrointestinal procedure	Requires preauthorization only for treatment of Barrett’s esophagus with dysplasia	Yes	No
43644		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43645		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43647		Invesitgational and experimental procedures	Invesitgational and experimental procedures		Yes	Yes
43648		Invesitgational and experimental procedures	Invesitgational and experimental procedures		Yes	Yes
43659		Outpatient surgery for select procedures	Surgery - Stomach and intestines		Yes	Yes
43770		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43771		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43772		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43773		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43774		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43775		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43842		Investigational and experimental procedures	Investigational Weight Loss Surgery		Yes	Yes
43843		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43845		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43846		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43847		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43848		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43881		Invesitgational and experimental procedures	Invesitgational and experimental procedures		Yes	Yes
43882		Invesitgational and experimental procedures	Invesitgational and experimental procedures		Yes	Yes
43886		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43887		Outpatient services: Bariatric surgery	Surgery - Weight loss		Yes	Yes
43888		Outpatient services: 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 our musculoskeletal services provider	Yes	Yes
63001		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63003		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63005		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63011		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63012		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63015		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63016		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63017		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63020		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63030		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63035		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63040		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63042		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63043		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63044		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63045		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63046		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63047		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63048		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63050		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63051		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63055		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63056		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63057		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63064		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63066		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63075		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63076		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63077		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63078		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63081		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63082		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63085		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63086		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63087		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63088		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63090		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63091		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63101		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63102		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63103		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63170		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63172		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63173		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63185		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63190		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63191		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63194		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63195		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63196		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63197		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63198		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63199		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63200		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63250		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63251		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63252		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63265		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63266		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63267		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63268		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63270		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63271		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63272		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63273		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63275		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63276		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63277		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63278		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63280		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63281		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63282		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63283		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63285		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63286		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63287		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63290		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63295		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63300		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63301		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63302		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63303		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63304		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63305		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63306		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63307		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
63308		Surgery for select procedures	Surgery - Musculoskeletal	This service is preauthorized through our musculoskeletal services provider	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
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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
70540		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70542		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70543		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70544		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70545		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70546		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70547		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70548		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70549		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70551		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70552		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70553		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70554		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
70555		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
71250		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through National Imaging Associates (NIA).	Yes	Yes
71260		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through National Imaging Associates (NIA).	Yes	Yes
71270		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through National Imaging Associates (NIA).	Yes	Yes
71271		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This services is preauthorized through National Imaging Associates (NIA). Traditional Producats do not require Preauth	Yes	No
71275		Diagnostic services: CT scans	X-ray/Imaging - cat scan	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
71550		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
71551		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
71552		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
71555		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
72141		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72142		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72146		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72147		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72148		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72149		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72156		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72157		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72158		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72159		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
72195		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72196		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72197		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
72198		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
73218		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73219		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73220		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73221		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73222		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73223		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73225		Diagnostic services: MRI	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
73718		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73719		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73720		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73721		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73722		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73723		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
73725		Diagnostic services: MRA	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
74181		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
74182		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
74183		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
74185		Diagnostic services: MRI	X-Ray/Imaging - MRA	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	No
74712		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
74713		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
75557		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
75559		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
75561		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
75563		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
75565		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
76390		Diagnostic services: SPECT	Nuclear medicine testing - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
77014		Therapy services: Radiation therapy , IGRT	Radiation therapy	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
77046		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
77047		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
77048		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
77049		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization	Yes	Yes
77084		Diagnostic services: MRI	X-Ray/Imaging - MRI	This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
78451		Diagnostic services: SPECT	X-Ray/Imaging -SPECT	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
78452		Diagnostic services: SPECT	X-Ray/Imaging -SPECT	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
78472		Diagnostic services: MUGA	Nuclear medicine testing - heart	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	Yes	Yes
78473		Diagnostic services: MUGA	Nuclear medicine testing - heart	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
78803		Diagnostic services:	X-Ray/Imaging -SPECT	This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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
81168		Diagnostic services: 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
81191		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81192		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81193		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81194		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81200		Lab/Genetic testing	Lab/Genetic testing		Yes	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
81278		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81279		Diagnostic services: 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
81338		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81339		Diagnostic services: 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
81347		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81348		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81350		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81351		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81352		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81353		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81357		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81360		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	No
81361		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81362		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81363		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81364		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81400		Lab/Genetic testing	Lab/Genetic testing		Yes	Yes
81401		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81402		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81403		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81404		Diagnostic services: Genetic testing	Lab/Genetic testing		Yes	Yes
81405		Diagnostic services: 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
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	Yes	Yes
81542		Lab/Genetic testing	Lab/Genetic testing		No	Yes
81546		Diagnostic services: Genetic testing	Lab/Genetic testing	If test does not meet criteria in the policy, it would be invalid	Yes	No
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	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90283		Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90284		Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90378		Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
90867		Select outpatient behavioral health services	Investigational Nerve stimulator	This service is preauthorized through Beacon Health.	Yes	Yes
90868		Select outpatient behavioral health services	Investigational Nerve stimulator	This service is preauthorized through Beacon Health.	Yes	Yes
90869		Select outpatient behavioral health services	Investigational Nerve stimulator	This service is preauthorized through Beacon Health.	Yes	Yes
90870		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 preauthorization 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 preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 1 Applies to Fully Insured products	Yes	Yes
93668		Therapy services: Physical therapy	Physical therapy services		Yes	Yes
95782		Other services: Sleep studies facility based	Sleep studies		Yes	No
95783		Other services: Sleep studies facility based	Sleep studies		Yes	No
95800		Other services: Sleep studies facility based	Sleep studies		Yes	No
95801		Other services: Sleep studies facility based	Sleep studies		Yes	No
95805		Other services: Sleep studies facility based	Sleep studies		Yes	No
95806		Other services: Sleep studies facility based	Sleep studies	Preauthorization required when performed in a facility.	Yes	No
95807		Other services: Sleep studies facility based	Sleep studies		Yes	No
95808		Other services: Sleep studies facility based	Sleep studies		Yes	No
95810		Other services: Sleep studies facility based	Sleep studies		Yes	No
95811		Other services: Sleep studies facility based	Sleep studies		Yes	No
95930		Investigational and experimental procedures	Brain testing		Yes	No
95980		Investigational and experimental procedures	Investigational and experimental procedures		Yes	Yes
95982		Investigational and experimental procedures	Investigational and experimental procedures		Yes	Yes
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 Beacon Health.	Yes	No
97153		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	Yes	No
97154		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	Yes	No
97155		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	Yes	No
97156		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	Yes	No
97157		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	Yes	No
97158		Select outpatient behavioral health services	Behavioral health service	This service is preauthorized through Beacon Health.	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
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 continuous glucose monitoring system, 1 unit = 1 day Supply	Diabetic DME & supplies	Diabetic Supplies		Yes	No
A9277	Transmitter; external, for use with interstitial continuous glucose monitoring system	Diabetic DME & supplies	Diabetic Supplies		Yes	No
A9278	Receiver (monitor); external, for use with interstitial continuous glucose monitoring system	Diabetic DME & supplies	Diabetic Supplies		Yes	No
A9513	Lutetium LU 177, dotatate, therapeutic, 1 millicurie	Medical injectables/other non-injectable drugs	Medical specialty drug	Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.	Yes	Yes
A9590	Iodine i-131, Iobenguane, 1 mCi	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
B4149	Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Other services: 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	Enteral nutrition infusion pump - any type	Other services: enteral feeding and supplies	Special nutrient formula		Yes	Yes
B9998	NOC for enteral supplies	Other services: enteral feeding and supplies	DME supplies		Yes	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 neurostimulator	DME: prosthetic appliances and implants	Nerve stimulator	Facility code requires preauthorization	Yes	Yes
C1789	Prosthesis, breast (implantable)	Reconstructive or cosmetic services - breast procedures	Surgery - breast	Preauthorizaton not required for treatment of cancer.	Yes	Yes
C1820	Generator, neurostimulator (implantable), with rechargeable battery and charging system	Investigational and experimental procedures	Investigational and experimental procedures	Facility code requires preauth	Yes	Yes
C1821	Interspinous process distraction device (implantable)	DME: prosthetic appliances and implants	Prosthetic devices	This service is preauthorized through our musculoskeletal services provider	Yes	Yes
C1822	Generator, neurostimulator (implantable), high frequency , with rechargeable battery and charging system	Investigational and experimental procedures	Investigational Procedure	Facility code requires preauthorization	Yes	Yes
C1839	Iris prosthesis	DME: Prosthetic appliances and implants	Eye procedure		Yes	No
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, non-stranded, 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 preauthorization	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 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
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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 Preauthorization 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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	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 preauthorization	Yes	Yes
C9069	Injection, belantamab mafodontin-blmf	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. Preauthorization only for this specialty injectable	Yes	No
C9070	Injection, tafasitamab-cxix, 2 mg	Medical injectables/other non-injectable drugs	Medical specialty drug		Yes	No
C9072	Injection immune globulin (asceniv), 500mg	Medical injectables/other non-injectable drugs	Medical specialty drug		Yes	No
C9073	Brexubabtagene autoleucel, up to 200 million autologoug anti-cd 19 car positive viable t cells, including leukapheresis and dose preparation proceudres, per therapeutic dose tacaretus	Medical injectables/other non-injectable drugs	Medical specialty drug		Yes	No
C9081	Abecma (idecabtagene vicleucel)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
C9082	Jemperli (dostarlimb-gxly)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
C9084	Zynlonta (loncastuximab tesirine-lpyl)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
C9083	Rybrevant (amivantamab-vmjw)	Medical injectables/other non-injectable drugs	Medical specialty drug	This service is preauthorized by Capital Blue Cross for Commercial.	Yes	No
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 our musculoskeletal services provider	Yes	Yes
C9763	Cardiac Magnetic Resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging	Diagnostic services: MRI	Diagnostic services : MRI	This service is preauthorized through National Imaging Associates (NIA). Traditional Products do not require Preauth.	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

Web Content Viewer - Metadata

Page Properties DnD

Breadcrumb DnD

Web Content Viewer - Fixed Context

Single source preauthorization list

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 Blue Cross' files.

Do not disclose

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context