Single source preauthorization list

This information is not a guarantee of payment.

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

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

Payment or processing of actual claims is subject to a determination about the member’s benefits and eligibility at the time of processing and a determination that the services are medically necessary and appropriate. Other factors, including, but not limited to, outstanding or in-process claims, may affect actual totals. Information may change due to coverage alterations or cancellation. All information in our files is proprietary and confidential to Capital Blue Cross and is to be used only for its intended purposes.

Do not disclose

  • CPT and revenue code descriptions are subject to copyright and therefore not included on the external single source preauthorization code list.
  • Preauthorization is required for the following list of items that are not necessarily listed separately by code: all inpatient admissions and observation care over 48 hours or; 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 January 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, 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 Benefits Booklet (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.
  • Applied Behavioral Analysis (ABA) services requiring preauthorization are listed below on the Single Source Preauthorization Code list. Providers should submit the appropriate CPT codes listed below and no longer use H0032, H2014, H2019, H2020, H2021, and H2022 codes for ABA assessment or treatment.
  • Administrative services only (ASO)/ Self-funded groups: Please note that some self-funded employer groups may customize their plans with different benefits and preauthorization requirements. The provider can check authorization requirements at the service code level via the authorization portal.
  • Subject to the exceptions listed in the General Preauthorization Overview, codes requiring preauthorization are listed by code in this form.
Code HCPCS and dental code description Preauthorization category Type of care Comments Commercial BlueJourney

0314U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

0901

 

Select outpatient behavioral health services

Behavioral health service

Facility revenue code requires preauthorization

Yes

Yes

0944

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

No

Yes

0945

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

No

Yes

0001U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

0003U

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

0005U

 

Diagnostic Services: Genetic testing

Lab/Genetic testing

 

Yes

No

0016U

 

Diagnostic services : Genetic testing

Lab/Genetic testing

 

Yes

No

0017U

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

0018U

 

Investigational and experimental procedures

Diagnostic services : Genetic testing

 

Yes

No

0019U

 

Investigational and experimental procedures

Lab/Genetic testing

For BlueJourney covered if medically necessary

Yes

Yes

0021U

 

Investigational and experimental procedures

Lab/Genetic testing

 

Yes

Yes

0022U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

0023U

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

0026U

 

Diagnostic services/Genetic testing

Lab/Genetic testing

 

Yes

No

0027U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0029U

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

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

No

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

0069U

 

Diagnostic services: 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

0094U

 

Diagnostic services: Genetic testing

Lab/Genetic Testing

 

Yes

Yes

0111U

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

0138U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0152U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0153U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0154U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0155U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0157U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

No

0158U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

No

0159U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

No

0160U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

No

0161U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

No

0162U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0165T

 

Surgery for select procedures

Surgery - Musculoskeletal

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

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

0209U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

0245U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

No

0253T

 

Outpatient surgery for select procedures

Surgery - eye

 

Yes

No

0286U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0212U

 

Diagnostic services: MRI

Diagnostic services: MRI

 

Yes

Yes

0213U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0214U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0215U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

Yes

0218U

 

Diagnostic services: Genetic testing

Lab/genetic testing

 

Yes

Yes

0219T

 

Surgery for select procedures

Surgery - Musculoskeletal

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 medically necessary criteria on policy then invalid

Yes

Yes

0233U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

0234U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

If it does not meet the criteria on 2.326

Yes

Yes

0235U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

0237U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

0238U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

If it does not meet criteria on policy then invalid

Yes

No

0239U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

0250U

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

0252U

 

Diagnostic services: Genetic testing

Diagnostic services: Genetic testing

 

Yes

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

0277U

 

Diagnostic services: Genetic testing

Lab/genetic testing

 

Yes

Yes

0278U

 

Diagnostic services: Genetic testing

Lab/genetic testing

 

Yes

Yes

0282U

 

Diagnostic services: Genetic testing

Lab/genetic testing

 

Yes

Yes

0274T

 

Surgery for select procedures

Surgery - Musculoskeletal

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

0276U

Hematology (inherited thrombocytopenia), genomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid

Diagnostic services: genetic testing

Lab/genetic testing

 

Yes

Yes

0317U

Oncology (lung cancer), four-probe fish (3q29, 3p22.1, 10q22.3, 10cen) assay, whole blood, predictive algorithm generated evaluation reported as decreased or increased risk for lung cancer

Diagnostic services: genetic testing

Diagnostic services: genetic testing

 

Yes

Yes

0318U

Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood

Diagnostic services: genetic testing

Diagnostic services: genetic testing

 

Yes

Yes

0326U

 

Diagnostic services: genetic testing

Diagnostic services: genetic testing

 

Yes

Yes

0334U

 

Diagnostic services: genetic testing

Lab/genetic testing

 

Yes

Yes

0335U

 

Diagnostic services: genetic testing

Lab/genetic testing

 

Yes

Yes

0336U

 

Diagnostic services: genetic testing

Lab/genetic testing

 

Yes

Yes

0345T

 

Outpatient surgery for select procedures

Surgery - Heart valve

 

Yes

Yes

0362T

 

Investigational and experimental procedures

Behavioral health service

This service is preauthorized through Carelon.

Yes

No

0364U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0373T

 

Investigational and experimental procedures

Behavioral health service

This service is preauthorized through Carelon.

Yes

No

0375U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

No

Yes

0378U

 

Diagnostic Services: Genetic Testing

Diagnostic Services: Genetic Testing

 

Yes

Yes

0388U

Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection

Diagnostic Services: Genetic Testing

Lab/Genetic testing

 

Yes

Yes

0394T

 

Therapy services: Radiation therapy

Radiation therapy

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

0417U

 

Diagnostic services: Genetic testing

Lab/genetic testing

 

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

No

0450T

 

Investigational and experimental procedures

Investigational eye procedures

 

Yes

No

0474T

 

Investigational and experimental procedures

Investigational eye procedures

 

Yes

No

0483T

 

Outpatient surgery for select procedures

Surgery - Heart valve

 

Yes

Yes

0524T

 

Reconstructive or cosmetic services: Varicose veins

Varicose vein procedure

 

Yes

Yes

0552T

 

Other services: laser treatment

Wound care

 

Yes

Yes

0570

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0571

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0572

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0579

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0580

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0581

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0582

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0583

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0589

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0590

 

Other services: Home health care

Home health care

Facility revenue code requires preauthorization.

Yes

Yes

0624

 

Investigational and experimental procedures

Investigational Supply

Facility revenue code requires preauthorization.

Yes

Yes

0671T

 

Investigational and experimental procedures

Investigational eye procedures

 

Yes

No

0724T

 

Diagnostic Services es: mri

X-RAY/Imaging-mri

This service is preauthorized through National Imaging Associates (NIA)

Yes

Yes

0742T

 

Diagnostic Services es: spect

X-RAY/Imaging-Spect

This service is preauthorized through National Imaging Associates (NIA)

Yes

Yes

0784T

 

Surgery for select procedures

Surgery - musculoskeletal

This service is preauthorized through Turning Point.

Yes

No

0785T

 

Surgery for select procedures

Surgery - musculoskeletal

This service is preauthorized through Turning Point.

Yes

No

0786T

 

Surgery for select procedures

Nerve stimulator

  ;

Yes

No

0787T

 

Surgery for select procedures

Nerve stimulator

  ;

Yes

No

0790T

 

Surgery for select procedures

Surgery - musculoskeletal

This service is preauthorized through Turning Point.

Yes

No

0905

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

Yes

0906

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

Yes

0912

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

Yes

0913

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

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

11450

 

Reconstructive or cosmetic services: excision/lipectomy

Surgery-skin procedure

 

Yes

Yes

11451

 

Reconstructive or cosmetic services: excision/lipectomy

Surgery-skin procedure

 

Yes

Yes

11920

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

11921

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

11950

 

Other services: Bio-engineered skin or biological wound care

Skin procedure

 

Yes

Yes

11951

 

Other services: Bio-engineered skin or biological wound care

Skin procedure

 

Yes

Yes

11952

 

Other services: Bio-engineered skin or biological wound care

Skin procedure

 

Yes

Yes

11954

 

Other services: Bio-engineered skin or biological wound care

Skin procedure

 

Yes

Yes

11960

 

Other services: Bio-engineered skin or biological wound care

Skin procedure

 

Yes

Yes

11970

 

Other services: Bio-engineered skin or biological wound care

Skin procedure

Preauthorization not required for treatment of cancer.

Yes

Yes

11971

 

Other services: Bio-engineered skin or biological wound care

Skin procedure

Preauthorization not required for treatment of cancer.

Yes

Yes

15150

 

Other services: wound care products

Wound care

 

Yes

Yes

15155

 

Other services: wound care products

Wound care

 

Yes

Yes

15271

 

Other services: wound care products

Wound care

 

Yes

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

No

15781

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

No

15782

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

No

15783

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

No

15786

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

Yes

15788

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

Yes

15789

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

Yes

15792

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

Yes

15793

 

Reconstructive or cosmetic services: Dermabrasion

Skin procedure

 

Yes

Yes

15820

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

15821

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

15822

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

15823

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

15824

 

Reconstructive or cosmetic services: Rhytidectomy

Skin procedure

 

Yes

Yes

15825

 

Reconstructive or cosmetic services: Rhytidectomy

Skin procedure

 

Yes

Yes

15826

 

Reconstructive or cosmetic services: Rhytidectomy

Skin procedure

 

Yes

Yes

15828

 

Reconstructive or cosmetic services: Rhytidectomy

Skin procedure

 

Yes

Yes

15829

 

Reconstructive or cosmetic services: Rhytidectomy

Skin procedure

 

Yes

Yes

15830

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

No

15832

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15833

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15834

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15835

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15836

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15837

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15838

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15839

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15876

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15877

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

No

15878

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

15879

 

Reconstructive or cosmetic services: Excision /Lipectomy

Skin procedure

 

Yes

Yes

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

17106

 

Other services: Laser treatment

Skin procedure

 

Yes

No

17107

 

Other services: Laser treatment

Skin procedure

 

Yes

No

17108

 

Other services: Laser treatment

Skin procedure

 

Yes

No

17360

 

Reconstructive or cosmetic services: Acne surgery

Skin procedure

 

Yes

Yes

17380

 

Reconstructive or cosmetic services: Acne surgery

Surgery - Heart/Blood vessel

 

Yes

Yes

19296

 

Therapy services: Radiation therapy

Radiation therapy

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

No

19316

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19318

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

No

19325

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

No

19328

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19330

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19340

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

No

19342

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

No

19350

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

No

19355

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19357

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19361

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19364

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19367

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19368

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19369

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19370

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19371

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19380

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

Yes

19396

 

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer.

Yes

No

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

20605

 

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

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

22836

 

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

22837

 

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

22838

 

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

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

22860

 

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through Turning Point

Yes

Yes

22861

 

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through 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

27278

 

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

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

No

30410

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

0425U

 

Diagnostic Services: Genetic Testing

Lab/genetic testing

 

Yes

Yes

0426U

 

Diagnostic Services: Genetic Testing

Lab/genetic testing

 

Yes

Yes

30420

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

30430

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

30435

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

30450

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

30460

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

30462

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

30520

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

No

30620

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

31295

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

11/16/2020 - Changing from non-covered to preauthorization .  MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis

Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018

Yes

Yes

31296

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

11/16/2020 - Changing from non-covered to preauthorization .  MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis

Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018

Yes

Yes

31297

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

11/16/2020 - Changing from non-covered to preauthorization.  MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis

Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018

Yes

Yes

31298

 

Reconstructive or cosmetic services: repair nasal/septal defects

Surgery - nose/sinuses

 

Yes

Yes

31574

 

Reconstructive

Injection procedure

 

Yes

Yes

31591

 

Investigational and experimental procedures

Reconstructive or cosmetic services

 

Yes

Yes

31660

 

Surgery for select procedures

Surgery - Lung

 

Yes

Yes

31661

 

Surgery for select procedures

Surgery - Lung

 

Yes

Yes

32664

 

Surgery for select procedures

surgery-musculoskeletal

 

Yes

Yes

32850

 

Transplant surgeries

Organ/Tissue transplant - Lung

 

Yes

Yes

32851

 

Transplant surgeries

Organ/Tissue transplant - Lung

 

Yes

Yes

32852

 

Transplant surgeries

Organ/Tissue transplant - Lung

 

Yes

Yes

32853

 

Transplant surgeries

Organ/Tissue transplant - Lung

 

Yes

Yes

32854

 

Transplant surgeries

Organ/Tissue transplant - Lung

 

Yes

Yes

32855

 

Transplant surgeries

Organ/Tissue transplant - Lung

 

Yes

Yes

32856

 

Transplant surgeries

Organ/Tissue transplant - Lung

 

Yes

Yes

32998

 

Outpatient surgery for select procedures

Tumor Ablations

 

Yes

Yes

33270

 

Investigational and experimental procedures

Investigational heart procedures

 

Yes

No

33271

 

Investigational and experimental procedures

Investigational heart procedures

 

Yes

No

33273

 

Investigational and experimental procedures

Investigational heart procedures

 

Yes

No

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

Yes

33419

 

Outpatient surgery for select procedures

Surgery - Heart valve

 

Yes

Yes

33477

 

Outpatient surgery for select procedures

Surgery-heart valve

 

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

No

33980

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

No

33981

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

33982

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

33983

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34701

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34702

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34703

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34704

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34705

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34706

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34707

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

34708

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

36465

 

Reconstructive or cosmetic services: Varicose veins

Varicose vein procedure

 

Yes

No

36466

 

Reconstructive or cosmetic services: Varicose veins

Varicose vein procedure

 

Yes

No

36468

 

Reconstructive or cosmetic services: Varicose veins

Vein procedures

 

Yes

No

36470

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

36471

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

36475

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

36478

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

36482

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

No

37241

 

Outpatient surgery for select procedures

Surgery - Heart/Blood vessel

 

Yes

Yes

37500

 

Reconstructive or cosmetic services: Varicose veins

Vein procedures

 

Yes

No

37700

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37718

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37722

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37735

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37760

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37761

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37765

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37766

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37780

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

37785

 

Reconstructive or cosmetic services: Varicose veins

Surgery - Varicose vein

 

Yes

No

38205

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

Yes

38206

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

Yes

38207

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38208

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38209

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38210

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38211

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38212

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38213

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38214

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38215

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38230

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

Yes

38232

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

Yes

38240

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38241

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

No

38242

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

Yes

38243

 

Transplant surgeries

Blood or marrow stem cell transplants

 

Yes

Yes

43229

 

Outpatient surgery for select procedures

Gastrointestinal procedure

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

Yes

No

43270

 

Outpatient surgery for select procedures

Gastrointestinal procedure

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

Yes

No

43644

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43645

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43647

 

Outpatient services: bariatric surgery

Surgery – Weight loss

 

Yes

Yes

43648

 

Outpatient services: bariatric surgery

Surgery – Weight loss

 

Yes

Yes

43659

 

Outpatient surgery for select procedures

Surgery - Stomach and intestines

 

Yes

No

43770

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43771

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43772

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43773

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43774

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43775

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43842

 

Investigational and experimental procedures

Investigational Weight Loss Surgery

 

Yes

No

43843

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43845

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43846

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43847

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43848

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43881

 

Outpatient services: Bariatric surgery

Surgery – Weight loss

 

Yes

Yes

43882

 

Outpatient services: Bariatric surgery

Surgery – Weight loss

 

Yes

Yes

43886

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43887

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

43888

 

Outpatient services: Bariatric surgery

Surgery - Weight loss

 

Yes

No

44132

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

No

44133

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

No

44135

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

No

44136

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

No

44715

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

Yes

44720

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

Yes

44721

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

Yes

47133

 

Transplant surgeries

Organ/Tissue transplant - Intestine

 

Yes

Yes

47135

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47140

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47141

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47142

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47143

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47144

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47145

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47146

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47147

 

Transplant surgeries

Organ/Tissue transplant - Liver

 

Yes

Yes

47370

 

Outpatient surgery for select procedures

Tumor Ablations

 

Yes

Yes

47380

 

Outpatient surgery for select procedures

Tumor Ablations

 

Yes

Yes

47382

 

Outpatient surgery for select procedures

Tumor Ablations

 

Yes

Yes

48160

 

Transplant surgeries

Organ/Tissue transplant - Pancreas

 

Yes

No

48550

 

Transplant surgeries

Organ/Tissue transplant - Pancreas

 

Yes

Yes

48551

 

Transplant surgeries

Organ/Tissue transplant - Pancreas

 

Yes

Yes

48552

 

Transplant surgeries

Organ/Tissue transplant - Pancreas

 

Yes

Yes

48554

 

Transplant surgeries

Organ/Tissue transplant - Pancreas

 

Yes

No

48556

 

Transplant surgeries

Organ/Tissue transplant - Pancreas

 

Yes

Yes

50300

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50320

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50323

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50325

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50327

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50328

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50329

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50340

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50360

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50365

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

50380

 

Transplant surgeries

Organ/Tissue transplant - Kidney

 

Yes

Yes

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

61863

 

Outpatient surgery for select procedures

Surgery - Head/Face

 

Yes

Yes

61867

 

Outpatient surgery for select procedures

Surgery - Head/Face

 

Yes

Yes

61880

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

Yes

61885

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

Yes

61886

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

Yes

61888

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

Yes

61889

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

61891

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

61892

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

62287

 

Surgery for select procedures

Surgery - Musculoskeletal

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

63052

 

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

Yes

63053

 

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

63650

 

Nerve stimulators and devices

Nerve stimulator

 

Yes

No

63655

 

Nerve stimulators and devices

Nerve stimulator

 

Yes

No

63685

 

Nerve stimulators and devices

Nerve stimulator

 

Yes

No

64450

 

Office surgical procedures

Injection procedure

Requires preauthorization only when performed in a facility.

No

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

No

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

No

64568

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

64569

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

64570

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

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

64582

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

64583

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

64585

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

64590

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

64595

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

No

64596

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

Yes

64598

 

Outpatient surgery for select procedures

Nerve stimulator

 

Yes

Yes

64620

 

Office surgical procedures

Injection procedure

Requires preauthorization only when performed in a facility.

Yes

Yes

64633

 

Investigational and experimental procedures

Investigational Nerve Procedure

 

Yes

No

64635

 

Outpatient surgery for select procedures

Nerve Procedures

 

Yes

No

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

66989

 

Investigational and experimental procedures

Investigational eye procedures

 

Yes

No

66991

 

Investigational and experimental procedures

Investigational eye procedures

 

Yes

No

67900

 

Reconstructive or cosmetic services: Ptosis repair

Surgery - Eyelid

 

Yes

No

67901

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

67902

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

67903

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

67904

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

67906

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

67908

 

Reconstructive or cosmetic services: Blepharoplasty

Surgery - Eyelid

 

Yes

No

67909

 

Reconstructive or cosmetic services: Ptosis repair

Surgery - Eyelid

 

Yes

No

67911

 

Reconstructive or cosmetic services: Ptosis repair

Surgery - Eyelid

 

Yes

No

69300

 

Reconstructive or cosmetic services: Otoplasty

Surgery - Head/Face

 

Yes

Yes

69676

 

Surgery for select procedures

Surgery - Head/Face

 

Yes

Yes

69710

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69711

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69714

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69716

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69717

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69719

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69726

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69727

 

Outpatient surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69728

 

Dme: implantable device

Hearing testing and treatment

 

Yes

Yes

69729

 

Dme: implantable device

Hearing testing and treatment

 

Yes

Yes

69730

 

Surgery for select procedures

Hearing testing and treatment

 

Yes

Yes

69930

 

Surgery for select procedures

Hearing testing and treatment

 

Yes

No

70336

 

Diagnostic services: MRI

X-Ray/Imaging - MRI

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 Products 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: spect

X-Ray/Imaging -SPECT

 

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

Yes

Yes

78811

 

Diagnostic services: PET scans

X-Ray/Imaging - PET scan

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

78830

 

diagnostic services: spect

X-Ray/Imaging - PET scan

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

Yes

Yes

78831

 

diagnostic services: spect

X-Ray/Imaging - PET scan

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

Yes

Yes

78832

 

diagnostic services: spect

X-Ray/Imaging - PET scan

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

Yes

Yes

81105

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81106

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81107

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81108

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81109

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81110

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81111

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81112

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81120

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81121

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81161

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81162

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

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

 

Diagnostic services : Genetic testing

Lab/Genetic testing

 

Yes

No

81173

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81174

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81175

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

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

No

81201

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81202

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81203

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81204

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81205

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81206

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81207

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81208

 

Diagnostic services : Genetic testing

Lab/Genetic testing

 

Yes

No

81209

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81210

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

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

No

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

81226

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81227

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

81228

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81229

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81232

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81233

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81234

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81235

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81236

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

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

No

81243

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81244

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81245

Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; dna analysis or combined dna and rna analysis

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81246

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81250

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81251

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81252

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81253

 

Diagnostic services: Genetic testingg

Lab/Genetic testing

 

Yes

No

81254

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81255

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81256

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

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

No

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

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81276

 

Diagnostic services : Genetic testing

Lab/Genetic testing

 

Yes

No

81277

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81278

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

81283

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

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

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

No

81293

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81294

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81295

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81296

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81297

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81298

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81299

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81300

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81301

 

Diagnostic services : Genetic testing

Lab/Genetic testing

 

Yes

No

81302

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81303

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81304

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81305

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

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

No

81311

 

Investigational and experimental procedures

Investigational lab/Genetic testing

 

Yes

No

81312

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81314

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

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

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81321

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81322

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81323

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81324

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81325

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81326

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81327

 

Investigational and experimental procedures

Investigational lab/Genetic testing

 

Yes

No

81328

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81330

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81331

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81332

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81333

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81334

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81335

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81336

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81337

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81340

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81341

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81342

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81343

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81344

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81345

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81346

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81347

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

81348

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

81349

 

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

No

81402

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

81403

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81404

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81405

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81406

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81407

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81408

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

No

81410

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81411

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81412

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81413

 

Investigational and experimental procedures

Investigational lab/Genetic testing

 

Yes

No

81414

 

Investigational and experimental procedures

Investigational lab/Genetic testing

 

Yes

No

81415

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81416

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81417

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81418

 

Lab/Genetic testing

Lab/Genetic testing

 

No

Yes

81425

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81426

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81427

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81430

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

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

81441

 

Diagnostic services: 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

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81448

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81450

 

Diagnostic services: genetic testing

lab/Genetic testing

  ;

Yes

Yes

81451

 

Investigational and experimental procedures

Investigational lab/Genetic testing

Non covered for commercial product

No

Yes

81455

 

Diagnostic services: genetic testing

lab/Genetic testing

 

Yes

No

81456

 

Investigational and experimental procedures

Investigational lab/Genetic testing

Non covered for commercial product

No

Yes

81457

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

No

81458

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

No

81459

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

No

81460

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81462

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

No

81463

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

No

81464

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

No

81465

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

81470

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81471

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

No

81479

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

81493

 

Diagnostic services: Genetic testing

Lab/Genetic testing

Non covered for commercial product

No

Yes

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

 

Diagnostic services: Genetic testing

Lab/Genetic testing

 

Yes

Yes

81546

 

Diagnostic services: Genetic testing

Lab/Genetic testing

If test does not meet criteria in the policy, it would be invalid

Yes

No

81552

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

85300

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

85301

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

85302

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

85303

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

85305

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

85306

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

85307

 

Diagnostic services: genetic testing

Lab/Genetic testing

 

Yes

Yes

86152

 

Investigational and experimental procedures

Investigational lab test

 

Yes

Yes

86153

 

Investigational and experimental procedures

Investigational lab test

 

Yes

Yes

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

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

88271

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

88272

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

88273

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

88274

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

88275

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

88291

 

Lab/Genetic testing

Lab/Genetic testing

 

Yes

Yes

90281

 

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

90283

 

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

90284

 

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

90378

 

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

90587

 

Medical Injectables/Other Non-Injectable Drug

Medical Specialty Drug

 

Yes

No

90867

 

Select outpatient behavioral health services

Investigational Nerve stimulator

This service is preauthorized through Carelon.

Yes

Yes

90868

 

Select outpatient behavioral health services

Investigational Nerve stimulator

This service is preauthorized through Carelon.

Yes

Yes

90869

 

Select outpatient behavioral health services

Investigational Nerve stimulator

This service is preauthorized through Carelon.

Yes

Yes

90870

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

Yes

93228

 

Investigational and experimental procedures

Investigational and experimental procedures

 

Yes

No

93229

 

Investigational and experimental procedures

Investigational and experimental procedures

 

Yes

No

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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts do not require Preauthorization 1 applies to fully insured products

Yes

Yes

93668

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

94625

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

94626

 

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

95805

 

Other services: Sleep studies facility based

Sleep studies

 

Yes

No

95807

 

Other services: Sleep studies facility based

Sleep studies

 

Yes

No

95808

 

Other services: Sleep studies facility based

Sleep studies

 

Yes

No

95810

 

Other services: Sleep studies facility based

Sleep studies

Preauthorization is not required for pediatrics less than 18 years of age.

Yes

No

95811

 

Other services: Sleep studies facility based

Sleep studies

Preauthorization is not required for pediatrics less than 18 years of age.

Yes

No

95930

 

Investigational and experimental procedures

Brain testing

 

Yes

No

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

97010

 

Therapy services: Physical therapy

Physical therapy services

 

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

97037

 

Other services: laser treatment

Investigational laser therapy

 

Yes

No

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

No

97130

 

Therapy services: Occupational therapy

Therapy services: Occupational therapy

 

Yes

No

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 Carelon.

Yes

No

97153

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

No

97154

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

No

97155

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

No

97156

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

No

97157

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

Yes

No

97158

 

Select outpatient behavioral health services

Behavioral health service

This service is preauthorized through Carelon.

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

No

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

A4100

Skin substitute, fda cleared as a device, not otherwise specified

Other services: bio-engineered skin or biological wound care

Skin procedure

 

Yes

Yes

A4560

Neuromuscular electrical stimulator (NMES), disposable, replacement only

Nerve stimulators & devices

Nerve stimulators

 

Yes

Yes

A4290

Sacral Nerve stimulation test lead, each

Investigational and experimental procedures

Nerve stimulator

 

Yes

Yes

A9274

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

Diabetic DME & supplies

DME supplies

 

Yes

No

A9278

Receiver (monitor); external, for use with interstitial continuous glucose monitoring system

Diabetic DME & supplies

Diabetic Supplies

 

Yes

No

A9513

Lutetium LU 177, dotatate, therapeutic, 1 millicurie

Medical injectables/other non-injectable drugs

Medical specialty drug

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: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4150

Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4152

Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4153

Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4154

Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4155

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4157

Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4158

Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4159

Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4160

Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4161

Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B4162

Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

No

B9002

Enteral nutrition infusion pump - any type

Other services: enteral feeding and supplies

Special nutrient formula

 

Yes

Yes

B9998

NOC for enteral supplies

Other services: enteral feeding and supplies

DME supplies

 

Yes

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

Preauthorization not required for treatment of cancer.

Yes

Yes

C1820

Generator, neurostimulator (implantable), with rechargeable battery and charging system

Investigational and experimental procedures

Investigational and experimental procedures

Facility code requires preauth

Yes

Yes

C1821

Interspinous process distraction device (implantable)

DME: prosthetic appliances and implants

Prosthetic devices

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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 ASO group contracts 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 mafodotin-blmf

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. preauthorization only for this specialty injectable

Yes

No

C9070

Injection, tafasitamab-cxix, 2 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

 

Yes

No

C9072

Injection immune globulin (asceniv), 500mg

Medical injectables/other non-injectable drugs

Medical specialty drug

 

Yes

No

C9073

Brexucabtagene autoleucel, up to 200 million autologous anti-cd 19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose tacaretus

Medical injectables/other non-injectable drugs

Medical specialty drug

 

Yes

No

C9160

Injection, daxibotulinumtoxina-lanm, 1 unit

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

C9161

Injection, aflibercept hd, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

C9163

Injection, talquetamab-tgvs, 0.25 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

C9165

Injection, elranatamab-bcmm, 1 mg

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

D7820

Closed reduction of dislocation; joint manipulated into place; no surgical exposure

Office surgical procedures

Dental procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7870

Arthrocentesis; withdrawal of fluid from a joint space by aspiration

Office surgical procedures

Dental procedures

Requires preauthorization only performed in a facility.

Yes

Yes

D7880

Occlusal orthotic device, by report; presently includes splints provided for treatment of temporomandibular joint dysfunction.

Office surgical procedures

Dental procedures

Requires preauthorization only when performed in a facility.

Yes

No

D9942

Repair and/or reline of Occlusal GUARD

Office surgical procedures

Dental procedures

Requires preauthorization only when performed in a facility.

Yes

No

D9950

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

Office surgical procedures

Dental procedures

Requires preauthorization only when performed in a facility.

Yes

No

D9951

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

Office surgical procedures

Dental procedures

Requires preauthorization only when performed in a facility.

Yes

No

D9952

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

Office surgical procedures

Dental procedures

Requires preauthorization only when performed in a facility.

Yes

No

E0183

Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty

DME: hospital beds & supplies

DME supplies

 

Yes

No

E0193

Powered air flotation bed (low air Loss therapy )

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0194

Air fluidized bed

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0250

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0251

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0255

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0256

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0260

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0261

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0265

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

No

E0266

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

No

E0270

Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0277

Powered pressure-reducing air mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0290

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0291

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0292

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0293

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0294

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0295

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

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0296

Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

No

E0297

Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

No

E0300

Pediatric crib, hospital grade, fully enclosed, with or without top enclosure

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0301

Hospital bed, heavy-duty, extra wide, with Weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0302

Hospital bed, extra heavy-duty, extra wide, with Weight capacity greater than 600 pounds, with any type side rails, without mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0303

Hospital bed, heavy-duty, extra wide, with Weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0304

Hospital bed, extra heavy-duty, extra wide, with Weight capacity greater than 600 pounds, with any type side rails, with mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0328

Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0329

Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0462

Rocking bed, with or without side rails

DME: hospital beds & supplies

Hospital bed

 

Yes

Yes

E0465

Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

DME: ventilators & airway assist devices

DME device

 

Yes

Yes

E0466

Home ventilator, any type, used with Noninvasive interface, (e.g., mask, Chest shell)

DME: ventilators & airway assist devices

DME device

 

Yes

Yes

E0467

Home ventilator, multi-function Respiratory device, also performs any or all of the additional functions of Oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions

DME: ventilators & airway assist devices

DME device

 

Yes

Yes

E0470

Respiratory assist device, bi-level pressure capability, without backup rate feature, used with Noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

DME: ventilators & airway assist devices

DME: C-PAP & supplies

 

Yes

Yes

E0471

Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with Noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

DME: ventilators & airway assist devices

DME: C-PAP & supplies

 

Yes

Yes

E0472

Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device

DME: ventilators & airway assist devices

DME: C-PAP & supplies

 

Yes

Yes

E0481

Intrapulmonary percussive ventilation system and related accessories

DME: ventilators & airway assist devices

DME device

 

Yes

No

E0482

Cough stimulating device, alternating positive and negative airway pressure

DME: ventilators & airway assist devices

DME device

 

Yes

Yes

E0483

High frequency Chest Wall Oscillation air-pulse generator system, (includes hoses and vest), each

DME: ventilators & airway assist devices

DME device

 

Yes

Yes

E0486

Oral device/appliance used to reduce upper airway collapsibility, adjustable or Nonadjustable, custom fabricated, includes fitting and adjustment

DME: equipment

DME supplies

 

Yes

Yes

E0561

Humidifier, Non-heated, used with positive airway pressure device

DME: ventilators & airway assist devices

DME: C-PAP & supplies

 

Yes

Yes

E0562

Humidifier, heated, used with positive airway pressure device

DME: C-PAP & supplies

DME Supplies

 

No

Yes

E0601

Continuous positive airway pressure (CPAP) device

DME: c-pap & supplies

DME supplies

 

No

Yes

E0616

Implantable cardiac event recorder with memory, activator, and programmer

DME: implant

DME device

 

Yes

Yes

E0617

External defibrillator with integrated electrocardiogram analysis

Defibrillator & supplies

DME supplies

 

Yes

Yes

E0636

Multi-positional patient support system, with integrated lift, patient accessible controls

DME: patient lifts

DME supplies

 

Yes

Yes

E0673

Segmental gradient pressure pneumatic appliance, half leg

DME: compression devices

DME supplies

 

Yes

Yes

E0676

Intermittent limb compression device (includes all accessories), not otherwise specified

DME: compression devices

DME supplies

 

Yes

No

E0694

Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection

DME: equipment

DME supplies

 

Yes

Yes

E0745

Neuromuscular Stimulator, electronic shock unit

Nerve stimulators and devices

Nerve stimulator

 

Yes

Yes

E0747

Osteogenesis Stimulator, electrical, Noninvasive, other than spinal applications

Nerve stimulators and devices

Nerve stimulator

 

Yes

Yes

E0748

Osteogenesis Stimulator, electrical, Noninvasive, spinal applications

Nerve stimulators and devices

Nerve stimulator

 

Yes

Yes

E0764

Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program

Nerve stimulators and devices

Nerve stimulator

 

Yes

Yes

E0766

Electrical stimulation device used for cancer treatment, includes all accessories, any type

DME: prosthetic appliances and implants

Nerve stimulator

 

Yes

Yes

E0782

Infusion pump, implantable, Nonprogrammable (includes all components, e.g., pump, catheter, connectors, etc.)

DME: implant

DME pump

 

Yes

Yes

E0783

Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)

DME: implant

DME pump

 

Yes

Yes

E0784

External ambulatory infusion pump, insulin

Diabetic DME & supplies

Diabetic Supplies

 

Yes

Yes

E0785

Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement

DME: implant

DME pump

 

Yes

Yes

E0786

Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)

DME: implant

DME pump

 

Yes

Yes

E0787

External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing

DME: equipment

DME supplies

 

Yes

Yes

E0935

Continuous passive motion exercise device for use on knee only

DME: equipment

DME supplies

 

Yes

Yes

E0951

Heel loop/holder, any type, with or without ankle strap, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0952

Toe loop/holder, any type, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0953

Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0954

Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0955

Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0956

Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0957

Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0958

Manual wheelchair accessory, one-arm drive attachment, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0959

Manual wheelchair accessory, adapter for amputee, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0960

Wheelchair accessory, shoulder harness/straps or Chest strap, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0961

Manual wheelchair accessory, wheel lock brake extension (handle), each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0966

Manual wheelchair accessory, headrest extension, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0967

Manual wheelchair accessory, hand rim with projections, any type, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0968

Commode seat, wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E0969

Narrowing device, wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E0970

No. 2 footplates, except for elevating leg rest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E0971

Manual wheelchair accessory, anti-tipping device, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0973

Wheelchair accessory, adjustable height, Detachable armrest, complete assembly, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0974

Manual wheelchair accessory, anti-rollback device, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0978

Wheelchair accessory, positioning belt/safety belt/pelvic strap, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0980

Safety vest, wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E0981

Wheelchair accessory, seat upholstery, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0982

Wheelchair accessory, back upholstery, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0988

Manual wheelchair accessory, lever-activated, wheel drive, pair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0990

Wheelchair accessory, elevating leg rest, complete assembly, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0992

Manual wheelchair accessory, solid seat insert

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E0994

Armrest, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E0995

Wheelchair accessory, calf rest/pad, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1002

Wheelchair accessory, power seating system, tilt only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1003

Wheelchair accessory, power seating system, recline only, without shear reduction

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1004

Wheelchair accessory, power seating system, recline only, with mechanical shear reduction

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1005

Wheelchair accessory, power seating system, recline only, with power shear reduction

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1006

Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1007

Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1008

Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1009

Wheelchair accessory, addition to power seating system, power leg elevation system, including legrest, pair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1010

Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1011

Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1012

Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1014

Reclining back, addition to pediatric size wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1016

Shock absorber for power wheelchair, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1017

Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1018

Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1020

Residual limb support system for wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1028

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1029

Wheelchair accessory, ventilator tray, fixed

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1030

Wheelchair accessory, ventilator tray, gimbaled

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1035

Multi-positional patient transfer system, with integrated seat, operated by care giver, patient Weight capacity up to and including 300 lbs

DME: patient lifts

DME supplies

 

Yes

Yes

E1036

Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient Weight capacity greater than 300 lbs

DME: patient lifts

DME supplies

 

Yes

Yes

E1037

Transport chair, pediatric size

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1038

Transport chair, adult size, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1039

Transport chair, adult size, heavy-duty, patient Weight capacity greater than 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1050

Fully reclining wheelchair; fixed full-length arms, swing-away, Detachable, elevating leg rests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1060

Fully-reclining wheelchair, Detachable arms, desk or full-length, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1070

Fully-reclining wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1083

Hemi-wheelchair; fixed full-length arms, swing-away, Detachable, elevating leg rests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1084

Hemi-wheelchair, Detachable arms desk or full-length arms, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1085

Hemi-wheelchair, fixed full-length arms, swing-away Detachable footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1086

Hemi-wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1087

High strength lightweight wheelchair, fixed full-length arms, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1088

High strength lightweight wheelchair, Detachable arms desk or full-length, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1089

High-strength lightweight wheelchair, fixed-length arms, swing-away Detachable footrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1090

High-strength lightweight wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1092

Wide heavy-duty wheel chair, Detachable arms (desk or full-length), swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1093

Wide heavy-duty wheelchair, Detachable arms, desk or full-length arms, swing-away Detachable footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1100

Semi-reclining wheelchair, fixed full-length arms, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1110

Semi-reclining wheelchair, Detachable arms (desk or full-length) elevating legrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1130

Standard wheelchair, fixed full-length arms, fixed or swing-away Detachable footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1140

Wheelchair, Detachable arms, desk or full-length, swing-away Detachable footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1150

Wheelchair, Detachable arms, desk or full-length swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1160

Wheelchair, fixed full-length arms, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1161

Manual adult size wheelchair, includes tilt in space

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1170

Amputee wheelchair, fixed full-length arms, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1171

Amputee wheelchair, fixed full-length arms, without footrests or legrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1172

Amputee wheelchair, Detachable arms (desk or full-length) without footrests or legrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1180

Amputee wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1190

Amputee wheelchair, Detachable arms (desk or full-length) swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1195

Heavy-duty wheelchair, fixed full-length arms, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1200

Amputee wheelchair, fixed full-length arms, swing-away Detachable footrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1220

Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1221

Wheelchair with fixed arm, footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1222

Wheelchair with fixed arm, elevating leg rests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1223

Wheelchair with Detachable arms, footrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1224

Wheelchair with Detachable arms, elevating leg rests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1225

Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1226

Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1227

Special height arms for wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1228

Special back height for wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1229

Wheelchair, pediatric size, not otherwise specified

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1230

Power operated Vehicle (3- or 4-wheel nonhighway), specify brand name and model number

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1231

Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1232

Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1233

Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1234

Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1235

Wheelchair, pediatric size, rigid, adjustable, with seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1236

Wheelchair, pediatric size, folding, adjustable, with seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1237

Wheelchair, pediatric size, rigid, adjustable, without seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1238

Wheelchair, pediatric size, folding, adjustable, without seating system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1239

Power wheelchair, pediatric size, not otherwise specified

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1240

Lightweight wheelchair, Detachable arms, (desk or full-length) swing-away Detachable, elevating legrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1250

Lightweight wheelchair, fixed full-length arms, swing-away Detachable footrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1260

Lightweight wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1270

Lightweight wheelchair, fixed full-length arms, swing-away Detachable elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1280

Heavy-duty wheelchair, Detachable arms (desk or full-length) elevating legrests

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1285

Heavy-duty wheelchair, fixed full-length arms, swing-away Detachable footrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1290

Heavy-duty wheelchair, Detachable arms (desk or full-length) swing-away Detachable footrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1295

Heavy-duty wheelchair, fixed full-length arms, elevating legrest

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E1296

Special wheelchair seat height from floor

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1297

Special wheelchair seat depth, by upholstery

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E1298

Special wheelchair seat depth and/or width, by construction

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E2102

Adjunctive, non-implanted continuous glucose monitor or receiver

Diabetic DME and supplies

Diabetic supplies

 

Yes

No

E2201

Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 in and less than 24 in

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2202

Manual wheelchair accessory, nonstandard seat frame width, 24-27 in

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2203

Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 in

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2204

Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 in

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2205

Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2206

Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2208

Wheelchair accessory, cylinder tank carrier, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2209

Accessory, arm trough, with or without hand support, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2210

Wheelchair accessory, bearings, any type, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2211

Manual wheelchair accessory, pneumatic propulsion tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2212

Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2214

Manual wheelchair accessory, pneumatic caster tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2215

Manual wheelchair accessory, tube for pneumatic caster tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2216

Manual wheelchair accessory, foam filled propulsion tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2217

Manual wheelchair accessory, foam filled caster tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2218

Manual wheelchair accessory, foam propulsion tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2219

Manual wheelchair accessory, foam caster tire, any size, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2220

Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2221

Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2222

Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2224

Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2225

Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2226

Manual wheelchair accessory, caster fork, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2227

Manual wheelchair accessory, gear reduction drive wheel, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2228

Manual wheelchair accessory, wheel braking system and lock, complete, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2230

Manual wheelchair accessory, manual standing system

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E2231

Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2291

Back, planar, for pediatric size wheelchair including fixed attaching hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2292

Seat, planar, for pediatric size wheelchair including fixed attaching hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2293

Back, contoured, for pediatric size wheelchair including fixed attaching hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2294

Seat, contoured, for pediatric size wheelchair including fixed attaching hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2295

Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2310

Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2311

Power wheelchair accessory, electronic connection between wheelchair controller and 2 or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2312

Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2313

Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2321

Power wheelchair accessory, hand control interface, remote joystick, Nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2322

Power wheelchair accessory, hand control interface, multiple mechanical switches, Nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2323

Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2324

Power wheelchair accessory, chin Cup for chin control interface

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2325

Power wheelchair accessory, SIP and PUFF interface, Nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2326

Power wheelchair accessory, breath tube kit for SIP and PUFF interface

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2327

Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2328

Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2329

Power wheelchair accessory, head control interface, contact switch mechanism, Nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2330

Power wheelchair accessory, head control interface, proximity switch mechanism, Nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2340

Power wheelchair accessory, nonstandard seat frame width, 20-23 inches

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E2341

Power wheelchair accessory, nonstandard seat frame width, 24-27 inches

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E2342

Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E2343

Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E2351

Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2359

Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2361

Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g. gel cell, absorbed glassmat)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2363

Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2365

Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2366

Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2367

Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

E2368

Power wheelchair component, motor, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2369

Power wheelchair component, gear box, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2370

Power wheelchair component, motor and gear box combination, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2371

Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2373

Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2374

Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2375

Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2376

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2377

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2378

Power wheelchair component, actuator, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2381

Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2382

Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2383

Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2384

Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2385

Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2386

Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2387

Power wheelchair accessory, foam filled caster tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2388

Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2389

Power wheelchair accessory, foam caster tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2390

Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2391

Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2392

Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2394

Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2395

Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2396

Power wheelchair accessory, caster fork, any size, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2397

Power wheelchair accessory, lithium-based battery, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2398

Wheelchair accessory, dynamic positioning hardware for back

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2402

Negative pressure wound therapy electrical pump, Stationary or Portable

DME: equipment

DME pump

 

Yes

Yes

E2500

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2502

Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2504

Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2506

Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2508

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2510

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2511

Speech generating software program, for personal computer or personal digital assistant

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2512

Accessory for speech generating device, mounting system

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2599

Accessory for speech generating device, not otherwise classified

Investigational and experimental procedures

Speech devices

 

Yes

Yes

E2601

General use wheelchair seat cushion, width less than 22 inches, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2602

General use wheelchair seat cushion, width 22 inches or greater, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2603

Skin protection wheelchair seat cushion, width less than 22 inches, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2604

Skin protection wheelchair seat cushion, width 22 inches or greater, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2605

Positioning wheelchair seat cushion, width less than 22 inches, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2606

Positioning wheelchair seat cushion, width 22 inches or greater, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2607

Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2608

Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2609

Custom fabricated wheelchair seat cushion, any size

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2611

General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2612

General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2613

Positioning wheelchair back cushion, posterior, width less than 22 in, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2614

Positioning wheelchair back cushion, posterior, width 22 in or greater, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2615

Positioning wheelchair back cushion, posterior-lateral, width less than 22 in, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2616

Positioning wheelchair back cushion, posterior-lateral, width 22 in or greater, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2617

Custom fabricated wheelchair back cushion, any size, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2619

Replacement cover for wheelchair seat cushion or back cushion, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2620

Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2621

Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2622

Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2623

Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2624

Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2625

Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2626

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2627

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2628

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2629

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2630

Wheelchair accessory, shoulder elbow, mobile arm support, mono suspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2631

Wheelchair accessory, addition to mobile arm support, elevating proximal arm

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2632

Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E2633

Wheelchair accessory, addition to mobile arm support, supinator

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

E3000

Speech volume modulation system, any type, including all components and accessories

DME: Wheelchairs and accessories

Speech devices

 

Yes

No

G0068

Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes

Home care

Home intravenous (IV) therapy

 

No

Yes

G0069

Professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes

Home care

Home health care

 

No

Yes

G0070

Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 minutes

Home care

Home health care

 

No

Yes

G0129

Occupational therapy services requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization or intensive outpatient treatment program, per session (45 minutes or more)

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

G0151

Services performed by a qualified Physical therapist in the home health or hospice setting, each 15 minutes

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

G0152

Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

G0155

Services of clinical Social worker in home health or hospice settings, each 15 minutes

Other services: Home health care

Home health care

 

Yes

Yes

G0156

Services of home health/hospice aide in home health or hospice settings, each 15 minutes

Other services: Home health care

Home health care

 

Yes

Yes

G0157

Services performed by a qualified Physical therapist assistant in the home health or hospice setting, each 15 minutes

Therapy services: Physical therapy

Physical therapy services

 

Yes

No

G0158

Services performed by a qualified Occupational therapist assistant in the home health or hospice setting, each 15 minutes

Therapy services: Occupational therapy

Therapy services: Occupational therapy

 

Yes

No

G0159

Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

G0160

Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes

Therapy services: Occupational therapy

Occupational therapy services

 

Yes

Yes

G0162

Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an rn to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting)

Other services: Home health care

Home health care

 

Yes

Yes

G0166

External counter pulsation, per treatment session

Other services: external counter pulsation

Investigational heart procedures

Non covered for commercial product

No

Yes

G0179

Physician re-certification for medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per re-certification period

Other services: Home health care

Home health care

 

Yes

Yes

G0180

Physician certification for medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per certification period

Other services: Home health care

Home health care

 

Yes

Yes

G0181

Physician supervision of a patient receiving medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more

Other services: Home health care

Home health care

 

Yes

Yes

G0219

PET imaging whole body; melanoma for non-covered indications

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

G0237

Therapeutic Procedures to increase strength or endurance of Respiratory muscles, face-to-face, one-on-one, each 15 minutes (includes monitoring)

Therapy services: Physical therapy

Physical therapy services

 

Yes

No

G0238

Therapeutic Procedures to improve Respiratory function, other than described by G0237, one-on-one, face-to-face, per 15 minutes (includes monitoring)

Therapy services: Physical therapy

Physical therapy services

 

Yes

No

G0239

Therapeutic Procedures to improve Respiratory function or increase strength or endurance of Respiratory muscles, two or more individuals (includes monitoring)

Therapy services: Physical therapy

Physical therapy services

 

Yes

No

G0252

PET imaging, full and partial-ring pet scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)

Diagnostic services: PET scans

X-Ray/Imaging - PET scan

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

Yes

Yes

G0277

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

Therapy services: Hyperbaric oxygen

Hyperbaric oxygen

 

Yes

No

G0299

Direct skilled nursing services of A registered nurse (RN) in the home health or hospice setting, each 15 minutes

Other services: Home health care

Home health care

 

Yes

Yes

G0300

Direct skilled nursing services of A license practical nurse (LPN) in the home health or hospice setting, each 15 minutes

Other services: Home health care

Home health care

 

Yes

Yes

G0339

Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G0340

Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G0341

Percutaneous Islet cell Transplant, includes portal vein catheterization and infusion

Transplant surgeries

Organ/Tissue transplant - Islet cell (pancreas)

 

Yes

No

G0342

Laparoscopy for Islet cell Transplant, includes portal vein catheterization and infusion

Transplant surgeries

Organ/Tissue transplant - Islet cell (pancreas)

 

Yes

No

G0343

Laparotomy for Islet cell Transplant, includes portal vein catheterization and infusion

Transplant surgeries

Organ/Tissue transplant - Islet cell (pancreas)

 

Yes

No

G0490

Face-to-face home health Nursing visit by a rural health clinic (RHC) or federally qualified health center (FQHC) in an area with A shortage of home health agencies. (services limited to RN or LPN only).

Home care

Home health care

 

Yes

Yes

G0493

Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)

Home care

Home health care

 

Yes

Yes

G0494

Skilled services of A licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)

Home care

Home health care

 

Yes

Yes

G0495

Skilled services of A registered nurse (RN), in the training and/or education of A patient or family member, in the home health or hospice setting, each 15 minutes.

Home care

Home health care

 

Yes

Yes

G0496

Skilled services of A licensed practical nurse (LPN), in the training and/or education of A patient or family member, in the home health or hospice setting, each 15 minutes.

Home care

Home health care

 

Yes

Yes

G2067

Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2068

Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2069

Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2070

Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2071

Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2072

Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2073

Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2074

Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2075

Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a medicare-enrolled opioid treatment program)

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2086

Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2087

Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month

Select Outpatient Behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

No

Yes

G2168

Services performed by a Physical therapist assistant in the home health setting in the delivery of a safe and effective Physical therapy maintenance program, each 15 minutes

Therapy services: Physical therapy

Physical therapy services

 

Yes

Yes

G2169

Services performed by an Occupational therapist assistant in the home health setting in the delivery of a safe and effective Occupational therapy maintenance program, each 15 minutes

Therapy services: Occupational therapy

Therapy services: Occupational therapy

 

Yes

Yes

G6001

Ultrasonic guidance for placement of Radiation therapy fields

Therapy services: Radiation therapy , IGRT

Radiation therapy

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

Yes

Yes

G6002

Stereoscopic X-RAY guidance for localization of target volume for the delivery of Radiation therapy

Therapy services: Radiation therapy , IGRT

Radiation therapy

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

Yes

Yes

G6003

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: up to 5MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6004

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: 6-10MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6005

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: 11-19MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6006

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or No blocks: 20MEV or greater

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6007

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on A single treatment area, use of multiple blocks: up to 5MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6008

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on A single treatment area, use of multiple blocks: 6-10MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6009

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on A single treatment area, use of multiple blocks: 11-19MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6010

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on A single treatment area, use of multiple blocks: 20 MEV or greater

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6011

Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; up to 5MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6012

Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; 6-10MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6013

Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; 11-19MEV

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6014

Radiation treatment delivery,3 or more separate treatment areas, Custom Blocking, tangential ports, wedges, rotational beam, compensators, Electron beam; 20MEV or greater

Therapy services: Radiation therapy

Radiation therapy

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

Yes

Yes

G6015

Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session

Therapy services: Radiation therapy , IMRT

Radiation therapy

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

Yes

Yes

G6016

Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session

Therapy services: Radiation therapy , IMRT

Radiation therapy

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

Yes

Yes

G6017

Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3d positional tracking, gating, 3d surface tracking), each fraction of treatment

Therapy services: Radiation therapy , IGRT

Radiation therapy

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

Yes

Yes

H0015

Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

Select outpatient behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

Yes

No

H0018

Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem

Select outpatient behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

Yes

No

H0035

Mental health partial hospitalization, treatment, less than 24 hours

Select outpatient behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

Yes

No

J0129

Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0172

Injection, aducanumab-avwa, 2 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J0174

Injection, lecanemab-irmb, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J0178

Injection, aflibercept, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J0638

Injection, canakinumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J0641

Injection, levoleucovorin, not otherwise specified, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

No

Yes

J0642

Injection, levoleucovorin (khapzory), 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

No

Yes

J2777

Injection, faricimab-svoa, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J0179

Injection, brolucizumab-dbll, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J0180

Injection, agalsidase beta, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0202

Injection, alemtuzumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0217

Injection, velmanase alfa-tycv, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J0218

Injection, olipudase alfa-rpcp, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0219

Injection, avalglucosidase alfa-ngpt, 4 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0221

Injection, alglucosidase alfa, (lumizyme), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0222

Injection, patisiran, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0223

Injection, givosiran, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0224

Injection, lumasiran, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

"This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

No

J0225

Injection, vutrisiran, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J0256

Injection, alpha 1- proteinase inhibitor (human), not otherwise specified, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J0257

Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J0490

Injection, belimumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J0491

Injection, anifrolumab-fnia, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

No

Yes

J0517

Injection, benralizumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0567

Injection, cerliponase alfa, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J0584

Injection, burosumab-twza, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J0585

Injection, onabotulinumtoxina, 1 unit

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0586

Injection, abobotulinumtoxina, 5 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthoirzed by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J0587

Injection, rimabotulinumtoxinB, 100 units

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J0588

Injection, incobotulinumtoxina, 1 unit

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthoirzed by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J0593

Injection, lanadelumab-flyo, 1 mg (code may be used for medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered.

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

No

Yes

J0596

Injection, C1 esterase inhibitor (recombinant), rucontest, 10 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J0597

Injection, C-1 esterase inhibitor (human), BERINERT, 10 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J0598

Injection, C-1 esterase inhibitor (human), CINRYZE, 10 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0717

Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0791

Injection, crizanlizumab-tmca, 5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0881

Injection, darbepoetin alfa, 1 mcg (non-esrd use)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0885

Injection, epoetin alfa, (for non-esrd use), 1000 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0888

Injection, epoetin beta, 1 mcg, (for non-esrd use)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0896

Injection, luspatercept-aamt, 0.25 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J0897

Injection, denosumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1290

Injection, ecallantide, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

No

J1300

Injection, eculizumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1301

Injection, edaravone, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J1302

INJECTION, SUTIMLIMAB-JOME, 10mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J1303

Injection, ravulizumab-cwvz, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J1304

Injection, tofersen, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J1305

Injection evkeeza (evinacumab-dgnb), 5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1306

Injection, inclisiran, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J1322

Injection, elosulfase alfa, 1mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1325

Injection, epoprostenol, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J1412

Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes.

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J1413

Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J1411

Injection, etranacogene dezaparvove-DRLB, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J1426

Injection, casimersen, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1427

Injection, viltolarsen, 10 mg

Medical injectiables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Captial BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J1428

Injection, eteplirsen, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1429

Injection, golodirsen, 10mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1437

Injection, ferric derisomaltose, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

No

Yes

J1439

Injection, ferric carboxymaltose, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

No

Yes

J1442

Injection, filgrastim (G-CSF), excludes biosimilars, 1 microgram

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1447

Injection, TBO-filgrastim, 1 microgram

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J1448

Injection, trilaciclib (cosela) , 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J1449

Injection, eflapegrastim-XNST, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J1458

Injection, galsulfase, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1459

Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1460

Injection, gamma globulin, intramuscular, 1 CC

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

No

Yes

J1551

Injection, immune globulin (cutaquig), 100 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for commercial.

Yes

No

J1555

Injection, immune globulin (cuvitru), 100 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1556

Injection, immune globulin (bivigam), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1557

Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1558

Injection, immune globulin (xembify), 100 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1559

Injection, immune globulin (hizentra), 100 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1560

Injection, gamma globulin, intramuscular, over 10 cc

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

No

J1561

Injection, immune globulin, (gamunex- c/gammaked), non-lyophilized (E. G. liquid), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1566

Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1568

Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1569

Injection, immune globulin, (gammagard liquid), non-lyophilized, (E. G. liquid), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1572

Injection, immune globulin, (flebogamma/flebogamma Dif), intravenous, non-lyophilized (e.g. liquid), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1575

Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immunoglobulin

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1576

Injection, immune globulin (panzyga), intravenous,non-lyophilized (e.g., liquid), 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J1599

Injection, immune globulin, intravenous, non-lyophylized (e.g., liquid), not otherwise specified, 500 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J1602

Injection, golimumab, 1 mg, for intravenous use

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1628

Injection, guselkumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J1743

Injection, idursulfase, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1745

Injection, infliximab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J1786

Injection, imiglucerase, 10 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1823

Injection, inebilizumab-cdon, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

"This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1931

Injection, laronidase, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J1951

Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J2182

Injection, mepolizumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J2323

Injection, natalizumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J2326

Injection, nusinersen, 0.1mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J2327

Injection, risankizumab-rzaa, intravenous, 1 mg (skyrizi)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J2329

Injection, ublituximab-xiiy, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J2350

Injection, ocrelizumab, 1mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J2357

Injection, omalizumab, 5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J2506

Injection, pegfilgrastim, excludes biosimilar, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J2507

Injection, pegloticase, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J2508

Injection, pegunigalsidase alfa-iwxj, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J2778

Injection, ranibizumab, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J2786

Injection, reslizumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J2793

Injection, rilonacept, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J2796

Injection, romiplostim, 10 micrograms

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J2820

Injection, sargramostim (GM-CSF), 50 mcg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J2840

Injection, sebelipase alfa, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J2998

Injection, plasminogen, human-tvmh, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthoirzed by Capital Blue Cross for Commercial. PRIME Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J3032

Injection, eptinezumab-jjmr, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J3060

Injection, taliglucerase alfa, 10 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3111

Injection, romosozumab-aqqg, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

"This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J3241

Injection, teprotumumab-trbw, 10 mg

Medical injectables/other non-injectable drugs

Injection procedure

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3245

Injection, tildrakizumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3262

Injection, tocilizumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3285

Injection, treprostinil, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J3357

Ustekinumab, for subcutaneous Injection, 1 mg Injection

Medical injectables/other non-injectable drugs

Medical specialty drug

 

Yes

No

J3358

Ustekinumab for intravenous injection, 1mg

 

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3380

Injection, vedolizumab, 1mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3385

Injection, velaglucerase alfa, 100 units

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3397

Injection, vestronidase alfa-vjbk, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J3398

Injection, voretigene neparvovec-rzyl, 1 billion vector genomes

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J3399

Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5X10^15 vector genomes

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9999 (Elrexfio)

Elrexfio (Elranatamab-bcmm) NDC 0069-2522-02 NDC 0069-4494-02 NDC 63539-252-02

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J9999 (Talvey)

Talvey (Talquetamab-tgvs) NDC 57894-469-01 NDC 57894-470-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J9999 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3401

Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector geomes, per 0.1ml

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.


Yes

No

J3490 (Rivfloza)

rivfloza (nedosiran) ndc 0169-5308-01 ndc 0169-5307-08 ndc 0169-5306-10

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3490 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3490 (Tegsedi)

Injection, tegsedi (inotersen) 1.5 ml in 1 syringe NDC 72126-007-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3490 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Daxxify)

Daxxify (Daxibotulinumtoxina-lamn) NDC 72960-111-01 NDC 72960-112-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (EYLEA HD)

Eyela HD (Aflibercept) NDC 61755-050-01 NDC 61755-051-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Entyvio SQ)

Entyvio, subcutaneous (vedolizumab) ndc 64764-0107-11 ndc 64764-0108-21

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Enspryng)

Enspryng (satralizumab)) - NDC 50242-007-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (LANTIDRA) )

Lantidra (Donislecel-jujn) NDC 73539-001-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (OMISIRGE)

Omisrge (Idubicel-onlv NDC 73441-800-04

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Pombiliti)

pombiliti (cipaglucosidase alfa-atga) ndc 71904-200-01 ndc 71904-200-02 ndc 71904-200-03

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Skysona)

Skysona (elivaldogene autotemcel) NDC - 73554-2111-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Tofidence)

tofidence (tocilizumab-bavi) ndc 64406-024-04, ndc 64406-022-01, ndc 64406-023-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (TYRUKO)

tyruko (natalizumab) ndc 61314-543-94

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Veopoz)

Veopoz (Pozelimab-bbfg) NDC 61755-014-01

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J3590 (Zynteglo)

Zynteglo (Betibeglogene Autotemcel) suspension for intravenous infusion

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation. J3590 requires PREAUTH only for this Specialty Injectable. Please fax the request and documentation to 866.805.4150.

Yes

No

J7179

Injection, von willebrand factor (recombinant), (vonvendi), 1 iu vwf:rco

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7170

Injection, emicizumab-kxwh, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7175

Injection, factor x, (human), 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7180

Injection, factor xiii (antihemophilic factor, human), 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7181

Injection, factor xiii a-subunit, (recombinant), per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7182

Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7183

Injection, von willebrand factor complex (human), wilate, 1 iu vwf:rco

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7185

Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7187

injection, von willebrand factor complex (humate-p), per iu vwf:rco

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7186

Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7188

Injection, factor viii (antihemophilic factor, recombinant) (obizur), per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7189

Factor VIIA (Antihemophilic, Recombinant), (Novoseven rt), 1MCG

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7190

Factor viii (antihemophilic factor, human) per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7192

Factor viii (antihemophilic factor, recombinant) per iu, not otherwise specified

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7193

Factor ix (antihemophilic factor, purified, nonrecombinant) per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7194

factor ix complex, per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7195

Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified

Medical injectables/ other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7194

Factor IX, Complex, per I.U.

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7198

Antiinhibitor, per I.U.

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7200

Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7201

Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7202

Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7203

Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7204

Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7205

Injection, factor viii fc fusion protein (recombinant), per iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7207

Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 iu

Medical injectables/ other non-injectable drugs.

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7208

Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi) 1 iu

Medical injectables/ other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7209

Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7210

Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 iu

Medical injectables/ other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7211

Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7212

Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 mcg

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7213

Injection, coagulation factor ix (recombinant), ixinity, 1 iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7214

Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii iu

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J7318

Hyaluronan or derivative, durolane, for intra- articular injection, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7320

Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7321

Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7322

Hyaluronan or derivative, hymovis, for intra- articular injection, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7324

Hyaluronan or derivative, orthovisc, for intra- articular injection, per dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7326

Hyaluronan or derivative, gel-one, for intra- articular injection, per dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7327

Hyaluronan or derivative, monovisc, for intra- articular injection, per dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7328

Hyaluronan or derivative, gel-syn, for intra- articular injection, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7329

Hyaluronan or derivative, trivisc, for intra- articular injection, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7330

Autologous cultured chondrocytes, implant

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

Yes

J7331

Hyaluronan or derivative, SYNOJOYNT, for intra-articular injection, 1 mg SYNOJOYNT and 1% sodium hyaluronate (J code for both drugs different NDC)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7332

Hyaluronan or derivative, TRILURON, for intra- articular injection, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J7352

Afamelanotide implant, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize services for BlueJourney through CoverMyMeds.

Yes

Yes

J9015

Injection, aldesleukin, per single use vial

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J9021

Injection, asparaginase, recombinant, (rylaze), 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9022

Injection, atezolizumab, 10mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9023

Injection, avelumab, 10mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9033

Injection, Bendamustine HCL (treanda), 1mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9035

Injection, bevacizumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9037

Injection, belantamab mafodotin-blmf, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9039

Injection, blinatumomab, 1 mcg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9042

Injection, brentuximab vedotin, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9043

Injection, cabazitaxel, 1 mg (Jevtana)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9047

Injection carfilzomib 1 mg (kyprolis)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9055

Injection, cetuximab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9061

Injection, amivantamab-vmjw, 2 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9063

Injection, mirvetuximab soravtansine-gynx, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9064

Cabazitaxel (SANDOZ), not Therapeutically equivalent to J9043, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J9144

Injection, daratumumab, 10mg and hyaluronidase-fihj

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Claims should be submitted with National Drug Code (NDC) and supporting documentation.

Yes

No

J9145

Injection, daratumumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9173

Injection, durvalumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9176

Injection, elotuzumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9203

Injection, gemtuzumab ozogamicin, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9210

Injection, emapalumab-lzsg, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J9204

Injection, mogamulizumab-kpkc, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial .

Yes

No

J9223

Injection, lurbinectedin, 0.1 mg (zepzelka)

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9228

Injection, ipilimumab (yervoy), 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9247

Injection, melphalan flufenamide hcl, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

No

Yes

J9258

Injection, paclitaxel protein-bound particles (teva) not therapeutically equivalent to j9264, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

J9259

Injection, paclitaxel protein-bound particles (american regent) not therapeutically equivalent to j9264, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9264

Injection, paclitaxel protein-bound particles, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9271

Injection, pembrolizumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9272

Injection, dostarlimab-gxly, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9273

Injection, tisotumab vedotin-tftv, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for commercial. Prime therapeutics llc will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9274

Injection, tebentafusp-tebn, 1 microgram

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for commercial. Prime therapeutics llc will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9281

Mitomycin pyelocalyceal instillation, 1 mg

Medical injectables/other non-injectable drugs

Injection procedure

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9286

Injection, glofitamab-gxbm, 2.5 mg

Medical injectables/other non-injectable drugs

Injection procedure

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9298

Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9299

Injection, nivolumab, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9301

Injection, obinutuzumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9302

Injection, ofatumumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9303

Injection, panitumumab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9305

Pemetrexed (alimta)

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9308

Injection, ramucirumab, 5mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9309

Injection, polatuzumab vedotin-piiq, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9311

Injection, rituximab 10 mg and hyaluronidase

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9312

Injection, rituximab, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9316

Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize services for Blue Journey through CoverMyMeds.

Yes

Yes

J9317

Injection, sacituzumab govitecan-hziy, 2.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial..

Yes

No

J9318

Injection, romidepsin, nonlyophilized, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9319

Injection, romidepsin, lyophilized, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This services is preauthorized by Capital Blue Cross for Commercial.

Yes

No

J9321

Injection, epcoritamab-bysp, 0.16mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9331

Injection, sirolimus protein-bound particles, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthoirzed by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9332

Injection, efgartigimod alfa-fcab, 2mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthoirzed by Capital Blue Cross for Commercial.

Yes

No

J9333

Injection, rozanolixizumab-noli, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthoirzed by Capital Blue Cross for Commercial.

Yes

No

J9334

Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthoirzed by Capital Blue Cross for Commercial.

Yes

No

J9345

Injection, Retifanlimab-dlwr, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

No

Yes

J9347

Injection, tremelimumab-actl, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9348

Injection, naxitamab-gqgk, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds .

Yes

Yes

J9349

Injection, tafasitamab-cxix, 2 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds .

Yes

Yes

J9354

Injection Ado-trastuzumab emtansine

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

J9355

Injection, Trastuzumab, excludes biosimilar, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9356

Injection, Trastuzumab, 10 mg and hyaluronidase-OYSK

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9358

Injection, fam-trastuzumab deruxtecan-nxki, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9359

Injection, loncastuximab tesirine-lpyl, 0.075 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for commercial. Prime therapeutics llc will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

J9380

Injection, teclistamab-cqyv, 0.5mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9381

Injection, teplizumab-mzwv, 5mcg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

J9400

Injection, ZIV-aflibercept, 1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

K0002

Standard HEMI (low seat) wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0004

High strength, lightweight wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0006

Heavy-duty wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0007

Extra heavy-duty wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0008

Custom manual wheelchair/base

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0009

Other manual wheelchair/base

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0010

Standard-Weight frame motorized/power wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0011

Standard-Weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0012

Lightweight Portable motorized/power wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0013

Custom motorized/power wheelchair base

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0014

Other motorized/power wheelchair base

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0015

Detachable, Nonadjustable height armrest, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0017

Detachable, adjustable height armrest, base, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0018

Detachable, adjustable height armrest, upper portion, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0019

Arm pad, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0020

Fixed , adjustable height armrest, pair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0037

High mount flip-up footrest, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0038

Leg strap, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0039

Leg strap, H STYLE, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0040

Adjustable angle footplate, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0041

Large size footplate, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0042

Standard size footplate, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0043

Footrest, lower extension tube, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0044

Footrest, upper hanger bracket, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0045

Footrest, complete assembly

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0046

Elevating leg rest, lower extension tube, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0047

Elevating leg rest, upper hanger bracket, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0050

Ratchet assembly

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0051

Cam release assembly, footrest or leg rest, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0052

Swingway, Detachable footrests, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0056

Seat height less than 17 in or equal to or greater than 21 in for A high-strength, lightweight, or Ultra lightweight wheelchair

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0065

Spoke protectors, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0069

Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0070

Rear wheel assembly, complete, with pneumatic tire, spokes or molded, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0071

Front caster assembly, complete, with pneumatic tire, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0072

Front caster assembly, complete, with semi-pneumatic tire, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0073

Caster Pin lock, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0077

Front caster assembly, complete, with solid tire, replacement only, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0098

Drive belt for power wheelchair, replacement only

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0105

IV hanger, each

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0195

Elevating legrests, pair (for use with capped rental wheelchair base)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0462

Temporary replacement for patient-owned equipment being repaired, any type

DME: equipment

DME Rental

 

Yes

Yes

K0606

Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

Defibrillator & supplies

DME supplies

 

Yes

No

K0669

Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0733

Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0739

Repair or non routine service for durable Medical equipment other than Oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

DME: equipment

DME Repair

 

Yes

Yes

K0744

Absorptive wound dressing for use with suction pump, home model, Portable, pad size 16 SQ in or less

No category on the Professional COC - only facility

Wound care

 

Yes

Yes

K0745

Absorptive wound dressing for use with suction pump, home model, Portable, pad size more than 16 SQ in but less than or equal to 48 SQ in

No category on the Professional COC - only facility

Wound care

 

Yes

Yes

K0746

Absorptive wound dressing for use with suction pump, home model, Portable, pad size, greater than 48 SQ in

No category on the Professional COC - only facility

Wound care

 

Yes

Yes

K0800

Power operated Vehicle, group 1 standard, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0801

Power operated Vehicle, group 1 heavy-duty, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0802

Power operated Vehicle, group 1 very heavy-duty, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0806

Power operated Vehicle, group 2 standard, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0807

Power operated Vehicle, group 2 heavy-duty, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0808

Power operated Vehicle, group 2 very heavy-duty, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0812

Power operated Vehicle, not otherwise classified

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0813

Power wheelchair, group 1 standard, Portable, sling/solid seat and back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0814

Power wheelchair, group 1 standard, Portable, captains chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0815

Power wheelchair, group 1 standard, sling/solid seat and back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0816

Power wheelchair, group 1 standard, captains chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0820

Power wheelchair, group 2 standard, Portable, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0821

Power wheelchair, group 2 standard, Portable, captains chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0822

Power wheelchair, group 2 standard, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0823

Power wheelchair, group 2 standard, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0824

Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0825

Power wheelchair, group 2 heavy-duty, captain's chair, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0826

Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0827

Power wheelchair, group 2 very heavy duty, captains chair, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0828

Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient Weight capacity 601 pounds or more

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0829

Power wheelchair, group 2 extra heavy duty, captains chair, patient Weight capacity 601 pounds or more

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0830

Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0831

Power wheelchair, group 2 standard, seat elevator, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0835

Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0836

Power wheelchair, group 2 standard, single power option, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0837

Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0838

Power wheelchair, group 2 heavy duty, single power option, captains chair, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0839

Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0840

Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 601 pounds or more

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0841

Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0842

Power wheelchair, group 2 standard, multiple power option, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0843

Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0848

Power wheelchair, group 3 standard, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0849

Power wheelchair, group 3 standard, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0850

Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0851

Power wheelchair, group 3 heavy duty, captains chair, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0852

Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0853

Power wheelchair, group 3 very heavy duty, captains chair, patient Weight capacity, 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0854

Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient Weight capacity 601 pounds or more

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0855

Power wheelchair, group 3 extra heavy duty, captains chair, patient Weight capacity 601 pounds or more

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0856

Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0857

Power wheelchair, group 3 standard, single power option, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0858

Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient Weight 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0859

Power wheelchair, group 3 heavy duty, single power option, captains chair, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0860

Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0861

Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0862

Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0863

Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0864

Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 601 pounds or more

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0868

Power wheelchair, group 4 standard, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0869

Power wheelchair, group 4 standard, captains chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0870

Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0871

Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient Weight capacity 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0877

Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0878

Power wheelchair, group 4 standard, single power option, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0879

Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0880

Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient Weight 451 to 600 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0884

Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0885

Power wheelchair, group 4 standard, multiple power option, captain's chair, patient Weight capacity up to and including 300 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0886

Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient Weight capacity 301 to 450 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

No

K0890

Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient Weight capacity up to and including 125 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0891

Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient Weight capacity up to and including 125 pounds

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0898

Power wheelchair, not otherwise classified

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0899

Power mobility device, not coded by DME PDAC or does not meet criteria

DME: Wheelchairs and accessories

Wheelchairs and accessories

 

Yes

Yes

K0900

Customized durable Medical equipment, other than wheelchair

DME: equipment

DME Rental

 

Yes

Yes

K1001

Electronic positional OBSTRUCTIVE SLEEP APNEA treatment, with sensor, includes all components and accessories, any type

DME: ventilators & airway assist devices

DME: C-PAP & supplies DME device

 

Yes

Yes

K1027

Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment

DME: C-PAP and supplies

DME device

 

Yes

Yes

L0452

TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0480

TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0482

TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0484

TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0486

TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0622

Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0624

Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0629

Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, SHOU

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0632

Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0634

Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce LOA

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0636

Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid latera

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0638

Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to R

DME: spinal orthotics

Orthotics

 

Yes

Yes

L0640

Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to XYPHOID, produces intracavitary pressure to reduce load on the intervertebral

DME: spinal orthotics

Orthotics

 

Yes

Yes

L1834

Knee orthotic (KO), without knee joint, rigid, custom fabricated

Knee orthotics

Orthotics

 

Yes

Yes

L1840

Knee orthotic (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated

Knee orthotics

Orthotics

 

Yes

Yes

L1844

Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

Knee orthotics

Orthotics

 

Yes

Yes

L1846

Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

Knee orthotics

Orthotics

 

Yes

Yes

L1900

Ankle foot orthosis, spring wire, dorsiflexion assist calf Band, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1904

Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1907

Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1920

Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1940

Ankle foot orthosis, plastic or other material , custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1945

Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1950

Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1960

Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1970

Ankle foot orthosis, plastic with ankle joint, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1980

Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf Band/cuff (single BAR 'BK' orthosis), custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L1990

Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf Band/cuff (double bar 'BK' orthosis), custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2000

Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single BAR 'AK' orthosis), custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2005

Knee ankle foot orthosis, any material, single or double upright, stance control, Automatic lock and Swing phase release, any type activation, includes ankle joint, any type, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2006

Knee ankle foot device, any material, single or double upright, Swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), Custom F

DME: ankle, foot and knee orthotics

DME device

 

Yes

Yes

L2010

Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single BAR 'AK' orthosis), without knee joint, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2020

Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'AK' orthosis), custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2030

Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'AK' orthosis), without knee joint, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2034

Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2036

Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2037

Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2038

Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2106

Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material , custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2108

Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2126

Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material , custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L2128

Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L3161

Foot, adductus positioning device, adjustable

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

No

L4205

Repair of orthotic device, labor component, per 15 minutes

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L4210

Repair of orthotic device, repair or replace minor parts

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L4631

Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material , includes straps and closures, custom fabricated

DME: ankle, foot and knee orthotics

Orthotics

 

Yes

Yes

L5000

Partial foot, shoe insert with longitudinal arch, toe filler

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5010

Partial foot, molded socket, ankle height, with toe filler

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5020

Partial foot, molded socket, tibial tubercle height, with toe filler

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5050

Ankle, symes, molded socket, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5060

Ankle, symes, metal frame, molded leather socket, articulated ankle/foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5100

Below knee, molded socket, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5105

Below knee, plastic socket, joints and thigh lacer, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5150

Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5160

Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5200

Above knee, molded socket, single axis constant friction knee, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5210

Above knee, short prosthesis, No knee joint ('stubbies'), with foot blocks, No ankle joints, each

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5220

Above knee, short prosthesis, No knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5230

Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5250

Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5270

Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5280

Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5301

Below knee, molded socket, shin, sach foot, endoskeletal system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5312

Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5321

Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5331

Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5341

Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5500

Initial, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, direct formed

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5505

Initial, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, direct formed

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5510

Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, molded to model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5520

Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, direct formed

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5530

Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, molded to model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5535

Preparatory, below knee 'PTB' type socket, Non-alignable system, No cover, sach foot, prefabricated, adjustable open end socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5540

Preparatory, below knee 'PTB' type socket, Non-alignable system, pylon, No cover, sach foot, laminated socket, molded to model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5560

Preparatory, above knee- knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, plaster socket, molded to model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5570

Preparatory, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, direct formed

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5580

Preparatory, above knee - knee disarticulation ischial level socket, Non-alignable system, pylon, No cover, sach foot, thermoplastic or equal, molded to model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5585

Preparatory, above knee - knee disarticulation, ischial level socket, Non-alignable system, pylon, No cover, sach foot, prefabricated adjustable open end socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5590

Preparatory, above knee - knee disarticulation ischial level socket, Non-alignable system, pylon no cover, sach foot, laminated socket, molded to model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5595

Preparatory, hip disarticulation hemipelvectomy, pylon, No cover, sach foot, thermoplastic or equal, molded to patient model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5600

Preparatory, hip disarticulation hemipelvectomy, pylon, No cover, sach foot, laminated socket, molded to patient model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5610

Addition to lower extremity, endoskeletal system, above knee, hydracadence system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5611

Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5613

Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5614

Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5615

Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxal, fluid swing and stance phase control.

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5616

Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5617

Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5618

Addition to lower extremity, test socket, symes

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5620

Addition to lower extremity, test socket, below knee

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5622

Addition to lower extremity, test socket, knee disarticulation

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5624

Addition to lower extremity, test socket, above knee

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5626

Addition to lower extremity, test socket, hip disarticulation

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5628

Addition to lower extremity, test socket, hemipelvectomy

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5629

Addition to lower extremity, below knee, acrylic socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5630

Addition to lower extremity, symes type, expandable wall socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5631

Addition to lower extremity, above knee or knee disarticulation, acrylic socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5632

Addition to lower extremity, symes type, 'PTB' brim design socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5634

Addition to lower extremity, symes type, posterior opening (Canadian) socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5636

Addition to lower extremity, symes type, medial opening socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5637

Addition to lower extremity, below knee, total contact

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5638

Addition to lower extremity, below knee, leather socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5639

Addition to lower extremity, below knee, wood socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5640

Addition to lower extremity, knee disarticulation, leather socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5642

Addition to lower extremity, above knee, leather socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5643

Addition to lower extremity, hip disarticulation, flexible inner socket, external frame

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5644

Addition to lower extremity, above knee, wood socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5645

Addition to lower extremity, below knee, flexible inner socket, external frame

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5646

Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5647

Addition to lower extremity, below knee suction socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5648

Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5649

Addition to lower extremity, ischial containment/narrow M-L socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5650

Additions to lower extremity, total contact, above knee or knee disarticulation socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5651

Addition to lower extremity, above knee, flexible inner socket, external frame

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5652

Addition to lower extremity, suction suspension, above knee or knee disarticulation socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5653

Addition to lower extremity, knee disarticulation, expandable wall socket

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5654

Addition to lower extremity, socket insert, symes, (kemlo, pelite, aliplast, plastazote or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5655

Addition to lower extremity, socket insert, below knee (kemlo, pelite, aliplast, plastazote or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5656

Addition to lower extremity, socket insert, knee disarticulation (kemlo, pelite, aliplast, plastazote or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5658

Addition to lower extremity, socket insert, above knee (kemlo, pelite, aliplast, plastazote or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5661

Addition to lower extremity, socket insert, multi-durometer symes

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5665

Addition to lower extremity, socket insert, multi-durometer, below knee

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5666

Addition to lower extremity, below knee, cuff suspension

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5668

Addition to lower extremity, below knee, molded distal cushion

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5670

Addition to lower extremity, below knee, molded supracondylar suspension ('PTS' or similar)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5671

Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5672

Addition to lower extremity, below knee, removable medial brim suspension

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5673

Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5676

Additions to lower extremity, below knee, knee joints, single axis, pair

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5677

Additions to lower extremity, below knee, knee joints, polycentric, pair

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5678

Additions to lower extremity, below knee, joint covers, pair

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5679

Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5680

Addition to lower extremity, below knee, thigh lacer, non-molded

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5681

Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5682

Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5683

Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial 

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5684

Addition to lower extremity, below knee, fork strap

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5685

Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5686

Addition to lower extremity, below knee, back check (extension control)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5688

Addition to lower extremity, below knee, waist belt, webbing

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5690

Addition to lower extremity, below knee, waist belt, padded and lined

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5692

Addition to lower extremity, above knee, pelvic control belt, light

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5694

Addition to lower extremity, above knee, pelvic control belt, padded and lined

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5695

Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene equal, each

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5696

Addition to lower extremity, above knee or knee disarticulation, pelvic joint

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5697

Addition to lower extremity, above knee or knee disarticulation, pelvic Band

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5698

Addition to lower extremity, above knee or knee disarticulation, silesian bandage

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5699

All lower extremity prostheses, shoulder harness

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5700

Replacement, socket, below knee, molded to patient model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5701

Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5702

Replacement, socket, hip disarticulation, including hip joint, molded to patient model

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5703

Ankle, symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5704

Custom shaped protective cover, below knee

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5705

Custom shaped protective cover, above knee

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5706

Custom shaped protective cover, knee disarticulation

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5707

Custom shaped protective cover, hip disarticulation

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5710

Addition, exoskeletal knee-shin system, single axis, manual lock

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5711

Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light-material

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5712

Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5714

Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5716

Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5718

Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5722

Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5724

Addition, exoskeletal knee-shin system, single axis, fluid swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5726

Addition, exoskeletal knee-shin system, single axis, external joints fluid swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5728

Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5780

Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5781

Addition to lower limb prothesis, vacuum pump, residual limb volume management and moisture evacuation system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5782

Addition to lower limb prothesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5785

Addition, exoskeletal system, below knee, ultra-light-material (titanium, carbon fiber or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5790

Addition, exoskeletal system, above knee, ultra-light-material (titanium, carbon fiber or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5795

Addition, exoskeletal system, hip disarticulation, ultra-light-material (titanium, carbon fiber or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5810

Addition, endoskeletal, knee-shin system, single axis, manual lock

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5811

Addition, endoskeletal, knee-shin system, single axis, manual lock, ultra-light-material

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5812

Addition, endoskeletal, knee-shin system, single axis, friction swing and stance phase control (safety knee)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5814

Addition, endoskeletal, knee-shin system, polycentric, hydraulic swing phase control , mechanical stance phase lock

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5816

Addition, endoskeletal, knee-shin system, polycentric, mechanical stance phase lock

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5818

Addition, endoskeletal, knee-shin system, polycentric, friction swing, and stance phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5822

Addition, endoskeletal, knee-shin system, single axis, pneumatic swing, friction stance phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5824

Addition, endoskeletal, knee-shin system, single axis, fluid swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5826

Addition, endoskeletal, knee-shin system, single axis, hydraulic swing phase control , with miniature high activity frame

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5828

Addition, endoskeletal, knee-shin system, single axis, fluid swing and stance phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5830

Addition, endoskeletal, knee-shin system, single axis, pneumatic/ Swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5840

Addition, endoskeletal knee/shin system, 4-BAR linkage or multiaxial, pneumatic swing phase control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5845

Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5848

Addition to endoskeletal knee-shin system, FLUID stance extension, dampening feature, with or without adjustability

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5850

Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5855

Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5856

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, Swing and stance phase, includes electronic sensor(s), any type

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5857

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, Swing phase only, includes electronic sensor(s), any type

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5858

Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5859

Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5910

Addition, endoskeletal system, below knee, alignable system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5920

Addition, endoskeletal system, above knee or hip disarticulation, alignable system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5925

Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5926

Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5930

Addition, endoskeletal system, high activity knee control frame

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5940

Addition, endoskeletal system, below knee, ultra-light-material (titanium, carbon fiber or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5950

Addition, endoskeletal system, above knee, ultralight material (titanium, carbon fiber or equal) -

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5960

Addition, endoskeletal system, hip disarticulation, ultra-light-material (titanium, carbon fiber or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5961

Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5962

Addition, endoskeletal system, below knee, flexible protective outer surface covering system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5964

Addition, endoskeletal system, above knee, flexible protective outer surface covering system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5966

Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5968

Addition to lower limb prothesis, multiaxial ankle with Swing phase active dorsiflexion feature

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5970

All lower extremity prostheses, foot, external keel, sach foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5971

All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5972

All lower extremity prostheses, foot, flexible keel

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5974

All lower extremity prostheses, foot, single axis ankle/foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5975

All lower extremity prosthesis, combination single axis ankle and flexible keel foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5976

All lower extremity prostheses, energy Storing foot (seattle carbon copy II or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5978

All lower extremity prostheses, foot, multiaxial ankle/foot

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5979

All lower extremity prosthesis, multi-axial ankle, dynamic response foot, one piece system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5980

All lower extremity prostheses, flex foot system

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5981

All lower extremity prostheses, flex-walk system or equal

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5982

All exoskeletal lower extremity prostheses, axial rotation unit

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5984

All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5985

All endoskeletal lower extremity prostheses, dynamic prosthetic pylon

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5986

All lower extremity prostheses, multi-axial rotation unit ('MCP' or equal)

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5987

All lower extremity prosthesis, shank foot system with vertical loading pylon

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5988

Addition to lower limb prothesis, vertical shock reducing pylon feature

Lower extremity: Prosthetics

Prosthetics

 

Yes

Yes

L5990

Addition to lower extremity prosthesis, user adjustable heel height

Lower extremity: Prosthetics

Prosthetics

 

Yes

No

L5991

Addition to lower extremity prosthesis, Osseointegrated External Prosthetic Connector

Lower extremity: Prosthetics

Prosthetics

 

Yes

No

L6000

Partial hand, thumb remaining

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6010

Partial hand, little and/or ring finger remaining

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6020

Partial hand, No finger remaining

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6050

Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6055

Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6100

Below elbow, molded socket, flexible elbow hinge, triceps pad

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6110

Below elbow, molded socket, (muenster or northwestern suspension types)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6120

Below elbow, molded double wall split socket, STEP-up hinges, half cuff

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6130

Below elbow, molded double wall split socket, stump activated locking hinge, half cuff

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6200

Elbow disarticulation, molded socket, outside locking hinge, forearm

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6205

Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6250

Above elbow, molded double wall socket, internal locking elbow, forearm

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6300

Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6310

Shoulder disarticulation, passive restoration (complete prosthesis)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6320

Shoulder disarticulation, passive restoration (shoulder CAP only)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6350

Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6360

Interscapular thoracic, passive restoration (complete prosthesis)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6370

Interscapular thoracic, passive restoration (shoulder CAP only)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6400

Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6450

Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6500

Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6550

Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6570

Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6580

Preparatory, wrist disarticulation or below elbow, single Wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, USMC or equal pylon, No cover, molded to patient model

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6582

Preparatory, wrist disarticulation or below elbow, single Wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, USMC or equal pylon, No cover, direct formed

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6584

Preparatory, elbow disarticulation or above elbow, single Wall plastic socket, friction wrist, locking elbow, figure of eight harness, Fair lead cable control, USMC or equal pylon, No cover, molded to patient model

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6586

Preparatory, elbow disarticulation or above elbow, single Wall socket, friction wrist, locking elbow, figure of eight harness, Fair lead cable control, USMC or equal pylon, No cover, direct formed

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6588

Preparatory, shoulder disarticulation or interscapular thoracic, single Wall plastic socket, shoulder joint, locking elbow, friction wrist, Chest strap, Fair lead cable control, USMC or equal pylon, No cover, molded to patient model

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6590

Preparatory, shoulder disarticulation or interscapular thoracic, single Wall socket, shoulder joint, locking elbow, friction wrist, Chest strap, Fair lead cable control, USMC or equal pylon, No cover, direct formed

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6600

Upper extremity additions, polycentric hinge, pair

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6605

Upper extremity additions, single pivot hinge, pair

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6610

Upper extremity additions, flexible metal hinge, pair

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6611

Addition to upper extremity prosthesis, external powered, additional switch, any type

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6615

Upper extremity addition, disconnect locking wrist unit

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6616

Upper extremity addition, additional disconnect insert for locking wrist unit, each

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6620

Upper extremity addition, flexion/extension wrist unit, with or without friction

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6621

Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6623

Upper extremity addition, spring assisted rotational wrist unit with latch release

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6624

Upper extremity addition, flexion/extension and rotation wrist unit

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6625

Upper extremity addition, rotation wrist unit with cable lock

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6628

Upper extremity addition, QUICK disconnect hook adapter, otto bock or equal

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6629

Upper extremity addition, QUICK disconnect lamination collar with coupling piece, otto bock or equal

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6630

Upper extremity addition, stainless steel, any wrist

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6632

Upper extremity addition, latex suspension sleeve, each

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6635

Upper extremity addition, lift assist for elbow

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6637

Upper extremity addition, nudge control elbow lock

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6638

Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6640

Upper extremity additions, shoulder abduction joint, pair

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6641

Upper extremity addition, excursion amplifier, pulley type

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6642

Upper extremity addition, excursion amplifier, lever type

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6645

Upper extremity addition, shoulder flexion-abduction joint, each

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6646

Upper extremity addition, shoulder joint, multi-positional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6647

Upper extremity addition, shoulder lock mechanism, body powered actuator

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6648

Upper extremity addition, shoulder lock mechanism, external powered actuator

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6650

Upper extremity addition, shoulder universal joint, each

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6655

Upper extremity addition, standard control cable, extra

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6660

Upper extremity addition, heavy duty control cable

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6665

Upper extremity addition, teflon, or equal, cable lining

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6670

Upper extremity addition, hook to hand, cable adapter

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6672

Upper extremity addition, harness, Chest or shoulder, SADDLE type

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6675

Upper extremity addition, harness, (e.g., figure of eight type), single cable design

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6676

Upper extremity addition, harness, (e.g., figure of eight type), dual cable design

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6677

Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6680

Upper extremity addition, test socket, wrist disarticulation or below elbow

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6682

Upper extremity addition, test socket, elbow disarticulation or above elbow

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6684

Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6686

Upper extremity addition, suction socket

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6687

Upper extremity addition, frame type socket, below elbow or wrist disarticulation

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6688

Upper extremity addition, frame type socket, above elbow or elbow disarticulation

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6689

Upper extremity addition, frame type socket, shoulder disarticulation

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6690

Upper extremity addition, frame type socket, interscapular-thoracic

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6691

Upper extremity addition, removable insert, each

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6692

Upper extremity addition, silicone gel insert or equal, each

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6693

Upper extremity addition, locking elbow, forearm counterbalance

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6694

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6695

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6696

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial 

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6697

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for Othe

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6698

Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6703

Terminal device, passive hand/MITT, any material, any size

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6704

Terminal device, Sport/recreational/work attachment, any material, any size

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6706

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6707

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6708

Terminal device, hand, mechanical, voluntary opening, any material, any size

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6709

Terminal device, hand, mechanical, voluntary closing, any material, any size

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6711

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6712

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6713

Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6714

Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6721

Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6722

Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6805

Addition to terminal device, modifier wrist unit

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6810

Addition to terminal device, precision pinch device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6881

Automatic grasp feature, addition to upper limb electric prosthetic terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6882

Microprocessor control feature, addition to upper limb prosthetic terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6883

Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6884

Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6885

Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6890

Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6895

Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6900

Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6905

Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6910

Hand restoration (casts, shading and measurements included), partial hand, with glove, No fingers remaining

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6915

Hand restoration (shading, and measurements included), replacement glove for above

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6920

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6925

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6930

Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6935

Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6940

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6945

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6950

Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6955

Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6960

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6965

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6970

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L6975

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal D

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7007

Electric hand, switch or myoelectric controlled, adult

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7008

Electric hand, switch or myoelectric, controlled, pediatric

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7009

Electric hook, switch or myoelectric controlled, adult

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7040

Prehensile actuator, switch controlled

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7045

Electric hook, switch or myoelectric controlled, pediatric

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7170

Electronic elbow, hosmer or equal, switch controlled

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7180

Electronic elbow, microprocessor sequential control of elbow and terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7181

Electronic elbow, microprocessor Simultaneous control of elbow and terminal device

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7185

Electronic elbow, adolescent, variety village or equal, switch controlled

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7186

Electronic elbow, child, variety village or equal, switch controlled

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7190

Electronic elbow, adolescent, variety village or equal, myoelectric-controlled controlled

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7191

Electronic elbow, child, variety village or equal, myoelectric-controlled controlled

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7259

Electronic wrist rotator, any type

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7400

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7401

Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7402

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7403

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7404

Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7405

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material

Upper extremity prosthetics

Prosthetics

 

Yes

Yes

L7510

Repair of prosthetic device, repair or replace minor parts

DME: prosthetic repair

DME Repair

 

Yes

Yes

L7520

Repair prosthetic device, labor component, per 15 minutes

DME: prosthetic repair

DME Repair

 

Yes

Yes

L8600

Implantable breast prosthesis, silicone or equal

Reconstructive or cosmetic services - breast procedures

Surgery - breast

Preauthorization not required for treatment of cancer.

Yes

Yes

L8612

Aqueous shunt

DME: implant

DME Implant

 

Yes

Yes

L8679

Implantable neurostimulator , pulse generator, any type [when specified as sacral Nerve stimulator]

DME: implant

Nerve stimulator

 

Yes

Yes

L8680

Implantable neurostimulator electrode, each

DME: implant

Nerve stimulator

 

Yes

Yes

L8681

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

Implant Supply

Nerve stimulator

 

Yes

Yes

L8682

Implantable neurostimulator radiofrequency receiver

DME: implant

Nerve stimulator

 

Yes

Yes

L8683

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

Implant Supply

Nerve stimulator

 

Yes

Yes

L8684

Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

Implant Supply

Nerve stimulator

 

Yes

Yes

L8685

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

DME: implant

Nerve stimulator

 

Yes

Yes

L8686

Implantable neurostimulator pulse generator, single array, No rechargeable, includes extension

DME: implant

Nerve stimulator

 

Yes

Yes

L8687

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

DME: implant

Nerve stimulator

 

Yes

Yes

L8688

Implantable neurostimulator pulse generator, dual array, Nonrechargeable, includes extension

DME: implant

Nerve stimulator

 

Yes

Yes

L8689

External recharging system for battery (internal) for use with implantable neurostimulator , replacement only

Implant Supply

DME supplies

 

Yes

Yes

L8690

Auditory osseointegrated device, includes all internal and external components

DME: equipment

DME device

 

Yes

No

L8691

Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each

DME: equipment

DME device

 

Yes

No

L8693

Auditory osseointegrated device abutment, any length, replacement only

DME: equipment

DME device

 

Yes

No

Q0138

Inection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use)

Medical injectables/other non-injectable drugs

Medical specialty drugs

Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

No

Yes

Q2041

Axicabtagene ciloleucel, up to 200 million Autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation Procedures, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q2042

Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation Procedures, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q2043

SIPULEUCEL-T, minimum of 50 million Autologous CD54+ cells activate with PAP-GM-CSF, including leukapheresis and all other Preparatory Procedures, per infusion

Medical injectables/other non-injectable drugs

Medical specialty drug

Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

No

Yes

Q2053

Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q2054

Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q2055

Idecabtagene vicleucel, up to 460 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q2056

Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q4100

Skin substitute, not otherwise specified

Other services: wound care products

Wound care

preauthorization required for all diagnosis other than breast cancer.

Yes

Yes

Q4101

Apligraf, per square centimeter

Other services: wound care products

Wound care

 

Yes

Yes

Q4102

Oasis wound matrix, per square centimeter

Other services: wound care products

Wound care

 

Yes

Yes

Q4103

Oasis BURN matrix, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4104

Integra Bilayer matrix wound dressing (BMWD), per square centimeter

Other services: wound care products

Wound care

Non covered commercial product

No

Yes

Q4105

Integra Dermal regeneration template (DRT), per square centimeter

Other services: wound care products

Wound care

 

Yes

Yes

Q4106

Dermagraft, per square centimeter

Other services: wound care products

Wound care

 

Yes

Yes

Q4107

Graftjacket, per square centimeter

Other services: wound care products

Wound care

preauthorization not required for treatment of breast cancer. All other diagnosis require preauthorization.

Yes

Yes

Q4108

Integra Matrix, per square centimeter

Other services: wound care products

Wound care

Non covered commercial product

No

Yes

Q4110

PriMatrix, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

preauthorization not required for breast Cancer diagnosis. All other diagnosis require preauthorization. Non covered for commercial product

No

Yes

Q4111

Gammagraft, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4115

AlloSkin, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4116

AlloDerm, per square centimeter

Other services: wound care products

Wound care

preauthorization not required for treatment of breast cancer. All other diagnosis, preauthorization required.

Yes

Yes

Q4117

Hyalomatrix, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4118

Matristem micromatrix, 1 mg

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4121

Theraskin, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4122

Dermacell, dermacell awm or dermacell awm porous, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

 

Yes

No

Q4123

AlloSkin RT, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4124

Oasis ultra TRI-LAYER wound matrix, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4126

Memoderm, dermaspan, tranzgraft or integuply, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4127

Talymed, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4128

Flex HD, or Allopatch HD, per square centimeter

Other services: wound care products

Wound care

Preauthorization not required for treatment of breast cancer. All other diagnosis require preauthorization.

Yes

No

Q4132

Grafix core, per square centimeter

Other services: Bio-engineered skin or biological wound care

Wound care

 

Yes

No

Q4133

GRAFIX Prime, GRAFIXPL Prime, STRAVIX and STRAVIXPL, per square centimeter

Other services: Bio-engineered skin or biological wound care

Wound care

 

Yes

No

Q4134

Hmatrix, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4135

Mediskin, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4136

EZ-DERM, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4137

AMNIOEXCEL, AMNIOEXCEL PLUS or BIODEXCEL, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4140

BioDFence, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4141

AlloSkin AC, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4146

TENSIX, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4147

Architect, architect px, or architect FX, extracellular matrix, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4151

Amnioband or guardian, per square centimeter

Other services: Bio-engineered skin or biological wound care

Wound care

 

Yes

No

Q4152

Dermapure, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4153

Dermavest, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4154

Biovance, per square centimeter

Other services: Bio-engineered skin or biological wound care

Wound care

 

Yes

No

Q4156

Neox 100, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4157

Revitalon, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4158

Marigen, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4159

Affinity, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

Yes

No

Q4160

Nushield, per square centimeter

Investigational and experimental procedures

Investigational wound care

Non covered for commercial product

No

Yes

Q4161

Bio-Connekt wound matrix, per square centimeter

Other services: wound care products

Wound care

Non covered commercial product

No

Yes

Q4163

AmnioPro, BioSkin, BioRenew, WoundEx, AMNIOGEN-45, AMNIOGEN-200, per square centimeter

Other services: wound care products

Wound care

 

No

Yes

Q4164

Helicoll, per square centimeter

Other services: wound care products

Wound care

Non covered for commercial product

No

Yes

Q4165

Keramatrix, per sq cm

Other services: wound care products

Wound care

Non covered for commercial product

No

Yes

Q4166

Cytal, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4168

Amnioband, 1 mg

Other services: Bio-engineered skin or biological wound care

Wound care

 

Yes

Yes

Q4173

Palingen or Palingen xplus, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4175

Miroderm, per square centimeter

Investigational and experimental procedures

Investigational wound treatment

Non covered for commercial product

No

Yes

Q4178

Floweramniopatch, per square centimeter

Other services: Bio-engineered skin or biological wound care

Wound care

Non covered for commercial product

No

Yes

Q4180

Revita, per square centimeter

Other services: Bio-engineered skin or biological wound care

Wound care

 

No

Yes

Q4186

Epifix, per square centimeter

Other services: wound care products

Wound care

 

Yes

No

Q4187

Epicord, per square centimeter

Other services: wound care products

Wound care

 

Yes

No

Q5101

Injection, filgrastim -sndz, biosimilar, (zarxio) 1 microgram

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

Q5103

Injection, infliximab-dyyb, biosimilar, (inflectra), 10mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

Q5104

Injection, infliximab-abda, biosimilar (renflexis), 10mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q5107

Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial. .

Yes

No

Q5108

Injection, pegfilgrastim-jmdb, (fulphila), biosimilar,0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q5110

Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

Q5111

Injection, pegfilgrastim-cbqv, (udenyca), biosimilar, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

Q5112

Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5113

Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5114

Injection, trastuzumab-dkst, biosimilar, (OGIVRI), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5115

Injection, rituximab-abbs, biosimilar (truxima), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

Q5118

Injection, bevacizumab-bzvr, biosimilar, (zirabev), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

Preauthorization is ONLY REQUIRED for treatment of a cancer diagnosis. This service is preauthorized by Capital BlueCross for Commercial.

Yes

No

Q5119

Injection, rituximab-pvvr, biosimilar (RUXIENCE), 10 mg

Medical injectables/other non-injectable drugs

Injection procedure

This service is preauthorized by Capital Blue Cross for Commercial.

Yes

No

Q5120

Injection, pegfilgrastim-bmez, (ZIEXTENZO), biosimilar, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q5121

Injection, infliximab-AXXQ, biosimilar, (AVSOLA), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q5122

Injection, pegfilgrastim-apgf, (nyvepria), biosimilar, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds.

Yes

Yes

Q5123

Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5124

Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5125

Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital Blue Cross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5126

Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5127

Injection, pegfilgrastim-FPGK (stimufend), biosimilar, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5128

Injection, ranibizumab-EQRN (cimeril), biosimilar, 0.1 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5129

Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial.Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

Q5130

Injection, pegfiLgrastim-PBBK (fylnetra), biosimilar, 0.5 mg

Medical injectables/other non-injectable drugs

Medical specialty drug

This service is preauthorized by Capital BlueCross for Commercial. Prime Therapeutics LLC will preauthorize service for Blue Journey through CoverMyMeds.

Yes

Yes

S0157

Becaplermin gel 0.01%, 0.5 GM

Investigational and experimental procedures

Wound care

Not valid for BlueJourney

Yes

No

S0201

partial hospitalization services, less than 24 hours, per diem

select outpatient behavioral health services

behavioral health services

This service is preauthorized through Carelon.

Yes

No

S0812

Phototherapeutic keratectomy (PTK)

Outpatient surgery for select procedures

Surgery - Eye

Not valid for BlueJourney

Yes

No

S1034

Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, Blood glucose device, insulin pump and computer algorithm that communicates with all of the devices

Diabetic DME & supplies

Diabetic Supplies

 

Yes

No

S1035

Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system

Diabetic DME & supplies

DME supplies

 

Yes

No

S1036

Transmitter; external, for use with artificial pancreas device system

Diabetic DME & supplies

DME supplies

 

Yes

No

S1037

Receiver (monitor); external, for use with artificial pancreas device system

Diabetic DME & supplies

DME supplies

 

Yes

No

S1040

Cranial remolding orthotic, pediatric, rigid, with soft interface material , custom fabricated, includes fitting and adjustment(s)

DME: equipment

Orthotics

 

Yes

No

S2053

Transplantation of small intestine, and liver allografts

Transplant surgeries

Organ/Tissue transplant - Intestine and Liver

Not valid for BlueJourney

Yes

No

S2054

Transplantation of multivisceral organs

Transplant surgeries

Organ/Tissue transplant - Multiple Organs

Not valid for BlueJourney

Yes

No

S2055

Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor

Transplant surgeries

Organ/Tissue transplant - Multiple Organs

Not valid for BlueJourney

Yes

No

S2060

Lobar lung transplantation

Transplant surgeries

Organ/Tissue transplant - Lung

Not valid for BlueJourney

Yes

No

S2061

Donor lobectomy (lung) for transplantation, living donor

Transplant surgeries

Organ/Tissue transplant - Lung

Not valid for BlueJourney

Yes

No

S2065

Simultaneous pancreas kidney transplantation

Transplant surgeries

Organ/Tissue transplant - Kidney

Not valid for BlueJourney

Yes

No

S2066

Breast reconstruction with gluteal artery perforator (gap) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer. Not valid for BlueJourney

Yes

No

S2067

Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast

Preauthorization not required for treatment of cancer. Not valid for BlueJourney

Yes

No

S2068

Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral

Reconstructive or cosmetic services: Breast procedures

Surgery - Breast Procedures

Preauthorization not required for treatment of cancer. Not valid for BlueJourney

Yes

No

S2083

Adjustment of Gastric Band diameter via subcutaneous port by injection or aspiration of Saline

Outpatient services: Bariatric surgery

Surgery - Weight loss

Not valid for BlueJourney

Yes

No

S2112

Arthroscopy, knee, Surgical for Harvesting of Cartilage (Chondrocyte cells)

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

S2118

Metal-on-metal total hip resurfacing, including acetabular and femoral components

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

S2140

Cord Blood Harvesting for transplantation, allogeneic

Transplant surgeries

Blood or marrow stem cell transplants

Not valid for BlueJourney

Yes

No

S2142

Cord Blood-derived stem-cell transplantation, allogeneic

Transplant surgeries

Blood or marrow stem cell transplants

Not valid for BlueJourney

Yes

No

S2150

Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and posttransplant care in the global definition

Transplant surgeries

Blood or marrow stem cell transplants

Not valid for BlueJourney

Yes

No

S2152

Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition

Transplant surgeries

Organ/Tissue transplant

Not valid for BlueJourney

Yes

No

S2202

Echosclerotherapy

Reconstructive or cosmetic services: Varicose veins

Varicose vein procedure

Not valid for BlueJourney

Yes

No

S2230

Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear

DME; Prosthetic appliance and implants

Hearing testing and treatment

 

Yes

No

S2348

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

S2350

Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

S2351

Diskectomy ant w/osteophytes; lumbar ed add in interspace

Surgery for select procedures

Surgery - Musculoskeletal

This service is preauthorized through our musculoskeletal services provider

Yes

No

S3800

Genetic testing for Amyotrophic Lateral Sclerosis (ALS)

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3844

DNA analysis of the connexin 26 Gene (GJB2) for susceptibility to congenital, profound deafness

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3845

Genetic testing for alpha-thalassemia

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3846

Genetic testing for hemoglobin E beta-thalassemia

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3850

Genetic testing for sickle cell anemia

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3853

Genetic testing for myotonic muscular dystrophy

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3861

Genetic testing, sodium channel, voltage-gated, Type V, Alpha Subunit (SCN5A) and variants for suspected Brugada Syndrome

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3866

Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S3870

Comparative genomic hybridization (CGH) microarray testing for developmental delay, Autism Spectrum Disorder and/or intellectual disability

Diagnostic services: Genetic testing

Lab/Genetic testing

Not valid for BlueJourney

Yes

No

S5108

Home care training to home care client, per 15 minutes

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S5109

Home care training to home care client, per session

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S5180

Home health Respiratory therapy , initial evaluation

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S5181

Home health Respiratory therapy , nos, per diem

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S8037

Magnetic Resonance Cholangiopancreatography (MRCP)

Diagnostic services: MRCP Scans

X-Ray/Imaging -MRI Scan

This service is preauthorized through National Imaging Associates (NIA). - Not valid for BlueJourney. - Traditional Products do not require preauthorization

Yes

No

S8092

Electron beam computed tomography (Also known as Ultrafast CT, Cine CT)

Diagnostic services: CT scans

Investigational X-Ray/Imaging Cat Scan

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

Yes

No

S8948

Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes

other services: laser treatment

skin procedure

 

Yes

No

S8950

Complex Lymphedema therapy, each 15 minutes

Investigational and experimental procedures

Lymphedema therapy

Not valid for BlueJourney

Yes

No

S8990

Physical or manipulative therapy performed for maintenance rather than restoration

Therapy services: Physical therapy

Physical therapy services

 

Yes

No

S9055

Procuren or other growth factor preparation to promote wound healing

Investigational and experimental procedures

Wound care

Not valid for BlueJourney

Yes

No

S9097

Home visit for wound care

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9098

Home visit, phototherapy services (e.g., bili-lite), including equipment rental, nursing services, blood draw, supplies, and other services, per diem

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9122

Home health aide or certified nurse assistant, providing care in the home; per hour

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9123

Nursing care the home; registered nurse per hour

Home care

Private duty nursing care in the home

Standard benefits exclude coverage. When a covered benefit, preauthorization is required - Not valid for BlueJourney

Yes

No

S9124

Nursing care, in the home; by licensed practical nurse, per hour

Home care

Private duty nursing care in the home

Standard benefits exclude coverage. When a covered benefit, preauthorization is required - Not valid for BlueJourney

Yes

No

S9127

Social work visit, in the home, per diem

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9129

Occupational therapy , in the home, per diem

Therapy services: Occupational therapy

Occupational therapy services

Not valid for BlueJourney

Yes

No

S9131

Physical therapy ; in the home, per diem

Therapy services: Physical therapy

Physical therapy services

Not valid for BlueJourney

Yes

No

S9208

Home management of preterm labor, including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately), per diem (do not use this code with any home infusion per diem code)

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9209

Home management of preterm premature rupture of membranes (pprom), including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately), per diem (do not use this code with any home infusion per diem code)

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9211

Home management of gestational hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code)

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9212

Home management of postpartum hypertension, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with any home infusion per diem code)

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9213

Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately); per diem (do not use this code with any home infusion per diem code)

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9214

Home management of gestational diabetes; diem

Other services: Home health care

Home health care

Not valid for BlueJourney

Yes

No

S9340

Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

Other services: enteral feeding and supplies

Special nutrient formula

Not covered for BlueJourney

Yes

No

S9341

Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

Other services: enteral feeding and supplies

Special nutrient formula

Not covered for BlueJourney

Yes

No

S9342

Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

Other services: enteral feeding and supplies

Special nutrient formula

Not covered for BlueJourney

Yes

No

S9343

Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

Other services: enteral feeding and supplies

Special nutrient formula

Not covered for BlueJourney

Yes

No

S9433

Medical food nutritionally complete, administered orally, providing 100% of nutritional intake

Other services: enteral feeding and supplies

Special nutrient formula

Not covered for BlueJourney

Yes

No

S9434

Modified solid food supplements for inborn errors of metabolism

Other services: enteral feeding and supplies

Special nutrient formula

Not covered for BlueJourney

Yes

No

S9435

Medical foods for inborn errors of metabolism

Other services: enteral feeding and supplies

Special nutrient formula

Not covered for BlueJourney

Yes

No

S9473

Pulmonary rehabilitation program, non-physician provider , per diem

Therapy services: Physical therapy

Physical therapy services

Not covered for BlueJourney

Yes

No

S9480

Intensive outpatient psychiatric services, per diem

Select outpatient behavioral health services

Behavioral health services

This service is preauthorized through Carelon.

Yes

No

S9960

Ambulance service, conventional air services, non emergency transport, one way (fixed wing)

Other services: Ambulance services -Non Emergent

Non emergency ambulance transport

Not covered for BlueJourney

Yes

No

S9961

Ambulance service, conventional air service, non emergency transport, one way (rotary wing)

Other services: Ambulance services -Non Emergent

Non emergency ambulance transport

Not covered for BlueJourney

Yes

No

T1000

Private duty/independent nursing service(s) - licensed, up to 15 minutes

Home care

Private duty Nursing care in the home

Standard benefits exclude coverage. When a covered benefit, preauthorization is required

Yes

No

T1001

Nursing assessment/evaluation

Other services: Home health care

Home health care

 

Yes

No

T1002

RN services, up to 15 minutes

Other services: Home health care

Home health care

 

Yes

No

T1003

LPN/LVN services, up to 15 minutes

Other services: Home health care

Home health care

 

Yes

No

T1004

Services of a qualified nursing aide, up to 15 minutes

Other services: Home health care

Home health care

 

Yes

No

T1005

Respite care services, up to 15 minutes

Other services: Home health care

Home health care

 

Yes

No

T1021

Home health aide or certified nurse assistant, per visit

Other services: Home health care

Home health care

 

Yes

No

T1022

Contracted home health agency services, all services provided under contract, per day

Other services: Home health care

Home health care

 

Yes

No

T1024

Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter

Therapy services: Physical medicine evaluations

Therapy evaluations

 

Yes

No

T1025

Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem

Therapy services: Physical medicine evaluations

Therapy evaluations

 

Yes

No

T1026

Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, medical and psychosocial impairments, per hour

Therapy services: Physical medicine evaluations

Therapy evaluations

 

Yes

No

T1027

Family training and counseling for child development, per 15 minutes

Therapy services: Physical medicine evaluations

Therapy evaluations

 

Yes

No

T1028

Assessment of home, Physical and family environment, to determine suitability to meet patient's medical needs

Therapy services: Physical medicine evaluations

Therapy evaluations

 

Yes

No

T1030

Nursing care, in the home, by registered nurse, per diem

Other services: Home health care

Home health care

 

Yes

No

T1031

Nursing care, in the home, by licensed practical nurse, per diem

Other services: Home health care

Home health care

 

Yes

No

T1502

Administration of oral, intramuscular and/or subcutaneous medication by health care Agency/Professional, per visit

Other services: Home health care

Home health care

 

Yes

No

T1503

Administration of medication, other than oral and/or injectable, by a health care Agency/Professional, per visit

Other services: Home health care

Home health care

 

Yes

No

T2007

Transportation waiting time, air ambulance and non-emergency vehicle, one-half (1/2) hour increments

Other services: ambulance services - non emergent

Non emergency ambulance transport

 

Yes

Yes

V2785

Processing, preserving and transporting corneal tissue

Transplant surgeries

Organ/Tissue transplant

 

Yes

Yes

V5095

Semi-implantable middle ear hearing prosthesis

DME; Prosthetic appliance and implants

Hearing testing and treatment

 

Yes

No