Single source preauthorization list
This information is not a guarantee of payment.
Benefits are subject to limitations in a member’s Certificate of Coverage and the member’s eligibility status.
The information being provided is based on information currently available in Capital Blue Cross' files.
Payment or processing of actual claims is subject to a determination regarding the member’s benefits and eligibility at the time of processing and a determination that the services are medically necessary and appropriate. Other factors, including, but not limited to, outstanding or in-process claims, may affect actual totals. Information may change due to coverage alterations or cancellation. All information on this computer system is proprietary and confidential to Capital Blue Cross and is to be used only for its intended purposes.
Do not disclose
- CPT and revenue code descriptions are subject to copyright and therefore not included on the external single source preauthorization code list. Please refer to the web or published manuals for a description of the service.
- Preauthorization is required for the following list of items that are not necessarily listed separately by code: All inpatient admissions and observation care over 48 hours; services/items that are considered by Capital Blue Cross medical policy to be experimental/investigational and possibly cosmetic.
- Preauthorization is required for non-routine maternity admissions, including preterm labor, maternity complications, and newborns requiring continued hospitalization after the mother is discharged.
- Effective 1/1/2020 DME/Orthotics/Prosthetic items requiring preauthorization will be individually listed below on the single source preauthorization code list. If the service is found, preauthorization is required on rentals and/or purchases. If not found below, then the DME service does not require preauthorization.
- Preauthorization does not generally apply to services/items that are specifically excluded from coverage under the member’s Certificate of Coverage. Therefore, these items may not appear on the preauthorization list.
- All services that are considered investigational/experimental or possibly cosmetic require documentation from the member’s medical record to ensure the item/service is medically necessary. Certain services may also require submission of photographs and are noted below.
- Please refer to Capital Blue Cross medical policy (or its delegated vendor) for medical necessity information.
- Refer to medical policy 3.015 entitled "office-based procedures performed in a facility" which is available on the Capital Blue Cross medical policy website for a list of services that require preauthorization when performed in a facility. These procedures can be safely performed in an office setting for most patients. Individual consideration can be given in the form of preauthorization for unique member conditions as outlined in the medical policy.
- Administrative services only (ASO)/ self-funded groups: Please note that some self-funded employer groups may customize their plans with different benefits and preauthorization requirements. The provider can check authorization requirements at the service code level via the authorization portal.
- Subject to the exceptions listed in the general preauthorization overview, codes requiring preauthorization are listed by code below.
Code | HCPCS and dental code description | Preauthorization category | Type of care | Comments | Commercial | BlueJourney |
---|---|---|---|---|---|---|
0901 |
|
Select outpatient behavioral health services |
Behavioral health service |
Facility revenue code requires preauthorization |
Yes |
Yes |
0944 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
No |
Yes |
0945 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
No |
Yes |
0001U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0003U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0005U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0009U |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
Yes |
0012U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0013U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0014U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0016U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0017U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0018U |
|
Investigational and experimental procedures |
Diagnostic services : Genetic testing |
|
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 |
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 |
Yes |
0040U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0042T |
|
Diagnostic services: CT scans |
X-ray/Imaging - Cat scan |
This service is preauthorized through National Imaging Associates (NIA). Traditional Products do not require preauthorization |
Yes |
Yes |
0046U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0047U |
|
Diagnostic services: Genetic testing |
Investigational lab/Genetic testing |
Non covered for commercial product |
Yes |
Yes |
0049U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
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 |
0129U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0130U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0131U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0132U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0133U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0134U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0135U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0136U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0137U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
No |
Yes |
0138U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0152U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0153U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0154U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0155U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0157U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
0158U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
0159U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
0160U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
0161U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
No |
0162U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0163T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
0165T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
0169U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0171U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0172U |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0173U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0177U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0180U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0181U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0182U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0183U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0184U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0185U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0186U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0187U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0188U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0189U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0190U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
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 |
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 |
0287U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0289U |
|
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 |
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 |
0236U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
0237U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0238U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
If it does not meet criteria on policy then invalid |
Yes |
No |
0239U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0250U |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
0252U |
|
Diagnostic services: Genetic testing |
Diagnostic services: Genetic testing |
|
Yes |
Yes |
0258U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0260U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0264U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0265U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0266U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0267U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0268U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0269U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0270U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0271U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0272U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0273U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0274U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0276U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0277U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0278U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0282U |
|
Diagnostic services: Genetic testing |
Lab/genetic testing |
|
Yes |
Yes |
0253T |
|
Outpatient surgery for select procedures |
Surgery - Eye |
|
Yes |
Yes |
0274T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
0275T |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
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 |
0345T |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
No |
0362T |
|
Investigational and experimental procedures |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
0373T |
|
Investigational and experimental procedures |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
0394T |
|
Therapy services: Radiation therapy |
Radiation therapy |
This service is preauthorized through National Imaging Associates (NIA). |
Yes |
Yes |
0395T |
|
Therapy services: Radiation therapy |
Radiation therapy |
This service is preauthorized through National Imaging Associates (NIA). |
Yes |
Yes |
0402T |
|
New to market service |
New Technology |
|
Yes |
Yes |
0413 |
|
Therapy services: Hyperbaric oxygen |
Hyperbaric oxygen |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0420 |
|
Therapy services: Physical therapy |
Physical therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0421 |
|
Therapy services: Physical therapy |
Physical therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0422 |
|
Therapy services: Physical therapy |
Physical therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0423 |
|
Therapy services: Physical therapy |
Physical therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0424 |
|
Therapy services: Physical therapy |
Physical therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0429 |
|
Therapy services: Physical therapy |
Physical therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0430 |
|
Investigational and experimental procedures |
Occupational therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0431 |
|
Therapy services: Hyperbaric oxygen |
Occupational therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0432 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0433 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0434 |
|
Therapy services: Hyperbaric oxygen |
Occupational therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0439 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0441T |
|
New to market service |
New Technology
|
|
Yes |
Yes |
0449T |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
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 |
No |
0524T |
|
Reconstructive or cosmetic services: Varicose veins |
Varicose vein procedure |
|
Yes |
Yes |
0570 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0571 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0572 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0579 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0580 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0581 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0582 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0583 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0584T |
|
Transplant surgeries |
Organ/Tissue transplant - Islet cell (pancreas) |
|
Yes |
No |
0585T |
|
Transplant surgeries |
Organ/Tissue transplant - Islet cell (pancreas) |
|
Yes |
No |
0586T |
|
Transplant surgeries |
Organ/Tissue transplant - Islet cell (pancreas) |
|
Yes |
No |
0589 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0590 |
|
Other services: Home health care |
Home health care |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0624 |
|
Investigational and experimental procedures |
Investigational Supply |
Facility revenue code requires preauthorization. |
Yes |
Yes |
0671T |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
Yes |
0905 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
0906 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
0912 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
0913 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
10040 |
|
Reconstructive or cosmetic services: Acne surgery |
Surgery - skin procedure |
|
Yes |
Yes |
11000 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
11001 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
11042 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
11043 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
11044 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
11450 |
|
Reconstructive or cosmetic services: excision/lipectomy |
Surgery-skin procedure |
|
Yes |
Yes |
11451 |
|
Reconstructive or cosmetic services: excision/lipectomy |
Surgery-skin procedure |
|
Yes |
Yes |
11750 |
|
Office surgical procedures |
Nail procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
11765 |
|
Office surgical procedures |
Nail procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
11920 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
11921 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
11950 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
11951 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
11952 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
11954 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
11960 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
11970 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
11971 |
|
Other services: Bio-engineered skin or biological wound care |
Skin procedure |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
12001 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
12011 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
15150 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
15155 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
15271 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
15273 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
15275 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
15277 |
|
Other services: wound care products |
Wound care |
|
Yes |
Yes |
15771 |
|
Reconstructive or cosmetic services: Breast procedures |
Reconstructive or cosmetic services: Augmentation and grafting |
|
Yes |
Yes |
15775 |
|
Reconstructive or cosmetic services: Hair transplant |
Hair transplant |
|
Yes |
Yes |
15776 |
|
Reconstructive or cosmetic services: Hair transplant |
Hair transplant |
|
Yes |
Yes |
15780 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
No |
15781 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
No |
15782 |
|
Reconstructive or cosmetic services: Dermabrasion |
Skin procedure |
|
Yes |
Yes |
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 |
Yes |
15821 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
Yes |
15822 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
15823 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
No |
15824 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
15825 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
15826 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
15828 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
15829 |
|
Reconstructive or cosmetic services: Rhytidectomy |
Skin procedure |
|
Yes |
Yes |
15830 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
No |
15832 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15833 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15834 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15835 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15836 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15837 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15838 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15839 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15876 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15877 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15878 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
15879 |
|
Reconstructive or cosmetic services: Excision /Lipectomy |
Skin procedure |
|
Yes |
Yes |
16000 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only performed in a facility. |
Yes |
Yes |
16020 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only performed in a facility. |
Yes |
Yes |
16025 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only performed in a facility. |
Yes |
Yes |
16030 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only performed in a facility. |
Yes |
Yes |
16035 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only performed in a facility. |
Yes |
Yes |
16036 |
|
Office surgical procedures |
Skin procedure |
Requires preauthorization only performed in a facility. |
Yes |
Yes |
17106 |
|
Other services: Laser treatment |
Skin procedure |
|
Yes |
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 |
Yes |
19316 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19318 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19325 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19328 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19330 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19340 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19342 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19350 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19355 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19357 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19361 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19364 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19367 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19368 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19369 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19370 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19371 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19380 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
19396 |
|
Reconstructive or cosmetic services: Breast procedures |
Surgery - Breast |
Preauthorization not required for treatment of cancer. |
Yes |
Yes |
20550 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
20551 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
20552 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
No |
20553 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
No |
20600 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
20605 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
20610 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
20612 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
20974 |
|
Investigational and experimental procedures |
Bone stimulator |
|
Yes |
Yes |
20975 |
|
Investigational and experimental procedures |
Bone stimulator |
|
Yes |
Yes |
20979 |
|
Investigational and experimental procedures |
Bone stimulator |
|
Yes |
Yes |
20982 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
21073 |
|
Investigational and experimental procedures |
Investigational TMJ treatment |
|
Yes |
Yes |
21116 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
21120 |
|
Other services: Augmentation and Grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21121 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21122 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21123 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21125 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21127 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21137 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21138 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21139 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21141 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21142 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21143
|
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21145 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21146 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21147 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21150 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21151 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21154 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21155 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21159 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21160 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21172 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21175 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21179 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21180 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21181 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21182 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21183 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21184 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21188 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21193 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21194 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21195 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21196 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21198 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21199 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21206 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21208 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21209 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21210 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21215 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21230 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21235 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21240 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21242 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21243 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21244 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21245 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21246 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21247 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21248 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21249 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21255 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21256 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21260
|
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21261 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21263 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21267 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21268 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21270 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21275
|
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21280 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Eye |
|
Yes |
Yes |
21282 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Eye |
|
Yes |
Yes |
21431 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21432 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21433 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21435 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21436 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Head/Face |
|
Yes |
Yes |
21740 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Chest |
|
Yes |
Yes |
21742 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Chest |
|
Yes |
Yes |
21743 |
|
Reconstructive or cosmetic services: Augmentation and grafting |
Surgery - Chest |
|
Yes |
Yes |
22220 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22222 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22224 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22226 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22510 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22511 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22512 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22513 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22514 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22515 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22532 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22533 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22534 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22548 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22551 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22552 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22554 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22556 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22558 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22585 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22586 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22590 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22595 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22600 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22610 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22612 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22614 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22630 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22632 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22633 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22634 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22800 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22802 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22804 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22808 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22810 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22812 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22818 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22819 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22830 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22849 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22856 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22857 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22858 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22861 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22862 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22864 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22865 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22867 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22868 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22869 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22870 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
22899 |
|
Surgery for select procedures |
Musculoskeletal Procedures |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23120 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider. |
Yes |
Yes |
23125 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23130 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23190 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23195 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23333 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23334 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23335 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23395 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23397 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23400 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23405 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23406 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23410 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23412 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23415 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23420 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23440 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23450 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23455 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23460 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23462 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23465 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23466 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23470 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23472 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23473 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23474 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23616 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23800 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
23802 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27033 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27090 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27091 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27120 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27122 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27125 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27130 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27132 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27134 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27137 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27138 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27146 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27147 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27151 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27156 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27158 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27161 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27236 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27279 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27280 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27284 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27286 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27299 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27403 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27405 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27407 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27409 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27412 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27415 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27416 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27418 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27420 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27422 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27424 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27425 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27427 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27428 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27429 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27437 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27438 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27440 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27441 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27442 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27443 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27445 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27446 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27447 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27486 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27487 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27488 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27570 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
27580 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
28446 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29827 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29850 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29851 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29855 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29856 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29860 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29861 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29862 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29863 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29866 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29867 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29868 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29870 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29871 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29873 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29874 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29875 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29876 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29877 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29879 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29880 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29881 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29882 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29883 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29884 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29885 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29886 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29887 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29888 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29889 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29914 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29915 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29916 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
29999 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider. |
Yes |
Yes |
30400 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
30410 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
30420 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
30430 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
30435 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
30450 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
No |
30460 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
30462 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
30520 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
30620 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
31295 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
11/16/2020 - Changing from non-covered to preauthorization . MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018 |
Yes |
Yes |
31296 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
11/16/2020 - Changing from non-covered to preauthorization . MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018 |
Yes |
Yes |
31297 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
11/16/2020 - Changing from non-covered to preauthorization. MP 1.119 Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis Code removed from Preauth-NCV-Medical Policy 4.002 effective 1/1/2018 |
Yes |
Yes |
31298 |
|
Reconstructive or cosmetic services: repair nasal/septal defects |
Surgery - nose/sinuses |
|
Yes |
Yes |
31574 |
|
Reconstructive |
Injection procedure |
|
Yes |
Yes |
31591 |
|
Investigational and experimental procedures |
Reconstructive or cosmetic services |
|
Yes |
Yes |
31660 |
|
Surgery for select procedures |
Surgery - Lung |
|
Yes |
Yes |
31661 |
|
Surgery for select procedures |
Surgery - Lung |
|
Yes |
Yes |
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 |
Yes |
33271 |
|
Investigational and experimental procedures |
Investigational heart procedures |
|
Yes |
Yes |
33273 |
|
Investigational and experimental procedures |
Investigational heart procedures |
|
Yes |
Yes |
33285 |
|
Outpatient surgery: Elective cardiac procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
33361 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
Yes |
33362 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
Yes |
33363 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
Yes |
33364 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
Yes |
33365 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
Yes |
33366 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
Yes |
33370 |
|
Outpatient surgery for select procedures |
Surgery - Heart/blood vessel |
|
Yes |
Yes |
33418 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
No |
33419 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
No |
33477 |
|
Outpatient surgery for select procedures |
Surgery - Heart valve |
|
Yes |
No |
33622 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
33927 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
33928 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
No |
33930 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart/Lung |
|
Yes |
Yes |
33933 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart/Lung |
|
Yes |
Yes |
33935 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart/Lung |
|
Yes |
Yes |
33940 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
33944 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
33945 |
|
Transplant surgeries |
Organ/Tissue transplant - Heart |
|
Yes |
Yes |
33975 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
33976 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
33977 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
33978 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
33979 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
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 |
34501 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34502 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34510 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34520 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34530 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34701 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34702 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34703 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34704 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34705 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34706 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34707 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
34708 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
36465 |
|
Reconstructive or cosmetic services: Varicose veins |
Varicose vein procedure |
|
Yes |
Yes |
36466 |
|
Reconstructive or cosmetic services: Varicose veins |
Varicose vein procedure |
|
Yes |
Yes |
36468 |
|
Reconstructive or cosmetic services: Varicose veins |
Vein procedures |
|
Yes |
No |
36470 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
36471 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
36475 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
36478 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
36482 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
37216 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
No |
Yes |
37241 |
|
Outpatient surgery for select procedures |
Surgery - Heart/Blood vessel |
|
Yes |
Yes |
37500 |
|
Reconstructive or cosmetic services: Varicose veins |
Vein procedures |
|
Yes |
Yes |
37700 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37718 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37722 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37735 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37760 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37761 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37765 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37766 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37780 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
37785 |
|
Reconstructive or cosmetic services: Varicose veins |
Surgery - Varicose vein |
|
Yes |
Yes |
38205 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
38206 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
38207 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38208 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38209 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38210 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38211 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38212 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38213 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38214 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38215 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
No |
38230 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
38232 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
38240 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
38241 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
38242 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
38243 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
41822 |
|
Office surgical procedures |
Dental procedures |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
41823 |
|
Office surgical procedures |
Dental procedures |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
41825 |
|
Office surgical procedures |
Dental procedures |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
41826 |
|
Office surgical procedures |
Dental procedures |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
41850 |
|
Office surgical procedures |
Dental procedures |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
43229 |
|
Outpatient surgery for select procedures |
Gastrointestinal procedure |
Requires preauthorization only for treatment of Barrett’s esophagus with dysplasia |
Yes |
No |
43270 |
|
Outpatient surgery for select procedures |
Gastrointestinal procedure |
Requires preauthorization only for treatment of Barrett’s esophagus with dysplasia |
Yes |
No |
43644 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
43645 |
|
Outpatient services: Bariatric surgery |
Surgery - Weight loss |
|
Yes |
No |
43647 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
Yes |
43648 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
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 |
Yes |
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 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
Yes |
43882 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
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 |
45300 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45303 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45305 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45307 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45308 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45309 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45315 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45317 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45320 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
45321 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
46230 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
46320 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
46924 |
|
Office surgical procedures |
Gastrointestinal procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
47133 |
|
Transplant surgeries |
Organ/Tissue transplant - Intestine |
|
Yes |
Yes |
47135 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47140 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47141 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47142 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47143 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47144 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47145 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47146 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47147 |
|
Transplant surgeries |
Organ/Tissue transplant - Liver |
|
Yes |
Yes |
47370 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
47380 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
47382 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
48160 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
No |
48550 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
48551 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
48552 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
48554 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
48556 |
|
Transplant surgeries |
Organ/Tissue transplant - Pancreas |
|
Yes |
Yes |
50300 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50320 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50323 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50325 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50327 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50328 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50329 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50340 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50360 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50365 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50380 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50542 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
50547 |
|
Transplant surgeries |
Organ/Tissue transplant - Kidney |
|
Yes |
Yes |
50592 |
|
Outpatient surgery for select procedures |
Tumor Ablations |
|
Yes |
Yes |
52441 |
|
Investigational and experimental procedures |
Investigational bladder procedure |
|
Yes |
Yes |
52442 |
|
Investigational and experimental procedures |
Investigational bladder procedure |
|
Yes |
Yes |
54065 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
55250 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
56820 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
56821 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
57420 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
57421 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
57452 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
57454 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
57455 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
57456 |
|
Office surgical procedures |
Genital/Reproductive procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
61630 |
|
Investigational and experimental procedures |
Investigational heart procedures |
Non covered for commercial product |
No |
Yes |
61863 |
|
Outpatient surgery for select procedures |
Surgery - Head/Face |
|
Yes |
Yes |
61867 |
|
Outpatient surgery for select procedures |
Surgery - Head/Face |
|
Yes |
Yes |
61880 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
61885 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
61886 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
61888 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
No |
62287 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63001 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63003 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63005 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63011 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63012 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63015 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63016 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63017 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63020 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63030 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63035 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63040 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63042 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63043 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63044 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63045 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63046 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63047 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63048 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63050 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
63051 |
|
Surgery for select procedures |
Surgery - Musculoskeletal |
This service is preauthorized through our musculoskeletal services provider |
Yes |
Yes |
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 |
64420 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
64421 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
64450 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
64451 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
64454 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
64553 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
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 |
Yes |
64583 |
|
Outpatient surgery for select procedures |
Nerve stimulator |
|
Yes |
Yes |
64584 |
|
Therapy services:Physical therapy |
Physical therapy services |
|
Yes |
Yes |
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 |
64620 |
|
Office surgical procedures |
Injection procedure |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
64624 |
|
Office surgical procedures |
Office surgical procedures |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
64633 |
|
Investigational and experimental procedures |
Investigational Nerve Procedure |
|
Yes |
Yes |
64635 |
|
Outpatient surgery for select procedures |
Nerve Procedures |
|
Yes |
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 |
Yes |
66991 |
|
Investigational and experimental procedures |
Investigational eye procedures |
|
Yes |
Yes |
67800 |
|
Office surgical procedures |
Surgery - Eyelid |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
67801 |
|
Office surgical procedures |
Surgery - Eyelid |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
67805 |
|
Office surgical procedures |
Surgery - Eyelid |
Requires preauthorization only when performed in a facility. |
Yes |
Yes |
67900 |
|
Reconstructive or cosmetic services: Ptosis repair
|
Surgery - Eyelid |
|
Yes |
Yes |
67901 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
Yes |
67902 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
Yes |
67903 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
Yes |
67904 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
Yes |
67906 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
Yes |
67908 |
|
Reconstructive or cosmetic services: Blepharoplasty |
Surgery - Eyelid |
|
Yes |
Yes |
67909 |
|
Reconstructive or cosmetic services: Ptosis repair
|
Surgery - Eyelid |
|
Yes |
Yes |
67911 |
|
Reconstructive or cosmetic services: Ptosis repair
|
Surgery - Eyelid |
|
Yes |
Yes |
68371 |
|
Transplant surgeries |
Organ/Tissue transplant - Conjunctiva (eye)
|
|
Yes |
Yes |
69300 |
|
Reconstructive or cosmetic services: Otoplasty |
Surgery - Head/Face |
|
Yes |
Yes |
69676 |
|
Surgery for select procedures |
Surgery - Head/Face |
|
Yes |
Yes |
69710 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
No |
69711 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
69714 |
|
Outpatient surgery for select procedures |
Hearing testing and treatment |
|
Yes |
Yes |
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 |
69930 |
|
Outpatient 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 |
78811 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization |
Yes |
Yes |
78812 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization |
Yes |
Yes |
78813 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization |
Yes |
Yes |
78814 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization |
Yes |
Yes |
78815 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization |
Yes |
Yes |
78816 |
|
Diagnostic services: PET scans |
X-Ray/Imaging - PET scan |
This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization |
Yes |
Yes |
81105 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81106 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81107 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81108 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81109 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81110 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81111 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81112 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81120 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81121 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81161 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81162 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81163 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81164 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81165 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81166 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81167 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81168 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81170 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81171 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81172 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81173 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81174 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81175 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81176 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81177 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81178 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81179 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81180 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81181 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81182 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81183 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81184 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81185 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81186 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81187 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81188 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81189 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81190 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81191 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81192 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81193 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81194 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81200 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81201 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81202 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81203 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81204 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81205 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81206 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81207 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81208 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81209 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81210 |
|
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 |
Yes |
81219 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81220 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81221 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81222 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81223 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81224 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81225 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81226 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81228 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81229 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81230 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81231 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81232 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81233 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81234 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81235 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81236 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81237 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81238 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81239 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81240 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81241 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81242 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81243 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81244 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81245 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81246 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81250 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81251 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81252 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81253 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81254 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81255 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81256 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81257 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81258 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81259 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81260 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81261 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81262 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81263 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81264 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81265 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81266 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81269 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81270 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81271 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81272 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81273 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81274 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81275 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81276 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81277 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81278 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81279 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81283 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81284 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81285 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81286 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81287 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81288 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81289 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81290 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81292 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81293 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81294 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81295 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81296 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81297 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81298 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81299 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81300 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81301 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81302 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81303 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81304 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81305 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81306 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81307 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81308 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81309 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81310 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81311 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
Yes |
81312 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81313 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81314 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81315 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81316 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81317 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81318 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81319 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81320 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81321 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81322 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81323 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81324 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81325 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81326 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81327 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
Yes |
81328 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81329 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81330 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81331 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81332 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81333 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81334 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81335 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81336 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81337 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81338 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81339 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81340 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81341 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81342 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81343 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81344 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81345 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81346 |
|
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 |
Yes |
81402 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81403 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81404 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81405 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81406 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81407 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81408 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81410 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81411 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81412 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81413 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
Yes |
81414 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
Yes |
81415 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81416 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81417 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81420 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81422 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
Yes |
81425 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81426 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81427 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81430 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81431 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81432 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81433 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81434 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81435 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81436 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81437 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81438 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81439 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
|
Yes |
Yes |
81440 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81442 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81443 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81445 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81448 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81450 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81455 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81460 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81465 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81470 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81471 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81479 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
|
Yes |
No |
81490 |
|
Investigational and experimental procedures |
Investigational lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81493 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81507 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
81538 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
5/1/2016 effective for Preauth. |
Yes |
Yes |
81540 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
5/1/2016 effective for Preauth. |
Yes |
Yes |
81541 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Non covered for commercial product |
Yes |
Yes |
81542 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
No |
Yes |
81546 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
If test does not meet criteria in the policy, it would be invalid |
Yes |
No |
81551 |
|
Diagnostic services: Genetic testing |
Lab/Genetic testing |
Non covered for commercial product |
No |
Yes |
81552 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
86152 |
|
Investigational and experimental procedures |
Investigational lab test |
|
Yes |
Yes |
86153 |
|
Investigational and experimental procedures |
Investigational lab test |
|
Yes |
Yes |
87900 |
|
Investigational and experimental procedures |
LAB test |
|
Yes |
Yes |
87901 |
|
Investigational and experimental procedures |
LAB test |
|
Yes |
Yes |
87903 |
|
Investigational and experimental procedures |
LAB test |
|
Yes |
Yes |
87906 |
|
Investigational and experimental procedures |
LAB test |
|
Yes |
Yes |
88240 |
|
Transplant surgeries |
Blood or marrow stem cell transplants |
|
Yes |
Yes |
88245 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88248 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88249 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88261 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88262 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88263 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88264 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88267 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88269 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88271 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88272 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88273 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88274 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88275 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88280 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88283 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88285 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88289 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
88291 |
|
Lab/Genetic testing |
Lab/Genetic testing |
|
Yes |
Yes |
90281 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
90283 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
90284 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
90378 |
|
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
90867 |
|
Select outpatient behavioral health services |
Investigational Nerve stimulator |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
90868 |
|
Select outpatient behavioral health services |
Investigational Nerve stimulator |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
90869 |
|
Select outpatient behavioral health services |
Investigational Nerve stimulator |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
90870 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
Yes |
90997 |
|
Investigational and experimental procedures |
Dialysis Procedure |
|
Yes |
Yes |
93228 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
Yes |
93229 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
Yes |
93303 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization 1 Applies to Fully Insured Products |
Yes |
Yes |
93304 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization 1 Applies to Fully Insured Products |
Yes |
Yes |
93306 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured Products |
Yes |
Yes |
93307 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured Products |
Yes |
Yes |
93308 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured Products |
Yes |
Yes |
93312 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured Products |
Yes |
Yes |
93313 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). Traditional products do not require preauthorization 1 applies to fully insured products |
Yes |
Yes |
93314 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
This service is preauthorized through National Imaging Associates (NIA). Traditional products do not require preauthorization 1 applies to fully insured products |
Yes |
Yes |
93315 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
93316 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
93317 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
93318 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
93350 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
93351 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
93352 |
|
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
93668 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
94625 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
94626 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
95782 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95783 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95800 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95801 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95805 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95806 |
|
Other services: Sleep studies facility based |
Sleep studies |
preauthorization required when performed in a facility. |
Yes |
No |
95807 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95808 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95810 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95811 |
|
Other services: Sleep studies facility based |
Sleep studies |
|
Yes |
No |
95930 |
|
Investigational and experimental procedures |
Brain testing |
|
Yes |
No |
95980 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
Yes |
95982 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
Yes |
96567 |
|
Investigational and experimental procedures |
Skin procedure |
|
Yes |
No |
96573 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
No |
96574 |
|
Investigational and experimental procedures |
Investigational and experimental procedures |
|
Yes |
No |
96920 |
|
Outpatient surgery for select procedures |
Treatment of skin diseases |
|
Yes |
Yes |
96921 |
|
Outpatient surgery for select procedures |
Treatment of skin diseases |
|
Yes |
Yes |
96922 |
|
Outpatient surgery for select procedures |
Treatment of skin diseases |
|
Yes |
Yes |
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 |
97039 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97110 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97112 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97113 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97116 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97124 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97129 |
|
Therapy services: Occupational therapy |
Therapy services: Occupational therapy |
|
Yes |
Yes |
97130 |
|
Therapy services: Occupational therapy |
Therapy services: Occupational therapy |
|
Yes |
Yes |
97139 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97140 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97150 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97151 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
97153 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
97154 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
97155 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
97156 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
97157 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
97158 |
|
Select outpatient behavioral health services |
Behavioral health service |
This service is preauthorized through Beacon Health. |
Yes |
No |
97161 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97162 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97163 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97164 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97165 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97166 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97167 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97168 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97530 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97533 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97535 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97542 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97750 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97755 |
|
Therapy services: Occupational therapy |
Occupational therapy services |
|
Yes |
Yes |
97760 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97761 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97763 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
97799 |
|
Therapy services: Physical therapy |
Physical therapy services |
|
Yes |
Yes |
99170 |
|
Office surgical procedures |
Hyperbaric oxygen |
Facility code requires preauthorization |
Yes |
Yes |
99183 |
|
Therapy services: Hyperbaric oxygen |
Hyperbaric oxygen |
|
Yes |
Yes |
99375 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99500 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99501 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99502 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99503 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99504 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99505 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99506 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99507 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99509 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
99511 |
|
Other services: Home health care |
Home health care |
|
Yes |
No |
A0430 |
Ambulance service, conventional air services, transport, one way (fixed wing) |
Office surgical procedures |
Non emergency ambulance transport |
|
Yes |
Yes |
A0431 |
Ambulance service, conventional air services, transport, one way (rotary wing) |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
|
Yes |
Yes |
A0435 |
Fixed wing air mileage, per statute mile |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
|
Yes |
Yes |
A0436 |
Rotary wing air mileage, per statute mile |
Other services: Ambulance services -Non Emergent |
Non emergency ambulance transport |
|
Yes |
Yes |
A4100 |
Skin substitute, fda cleared as a device, not otherwise specified |
Other services: bio-engineered skin or biological wound care |
Skin procedure |
|
Yes |
Yes |
A4290 |
Sacral Nerve stimulation test lead, each |
Investigational and experimental procedures |
Nerve stimulator |
|
Yes |
Yes |
A9274 |
External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories |
Diabetic DME & supplies |
DME supplies |
|
Yes |
No |
A9276 |
Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, 1 unit = 1 day Supply |
Diabetic DME & supplies |
Diabetic Supplies |
|
Yes |
No |
A9277 |
Transmitter; external, for use with interstitial continuous glucose monitoring system |
Diabetic DME & supplies |
Diabetic Supplies |
|
Yes |
No |
A9278 |
Receiver (monitor); external, for use with interstitial continuous glucose monitoring system |
Diabetic DME & supplies |
Diabetic Supplies |
|
Yes |
No |
A9513 |
Lutetium LU 177, dotatate, therapeutic, 1 millicurie |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
Prime Therapeutics LLC will preauthorize service for BlueJourney through CoverMyMeds. |
Yes |
Yes |
A9590 |
Iodine i-131, Iobenguane, 1 mCi |
Medical injectables/other non-injectable drugs |
Medical specialty drug |
This service is preauthorized by Capital Blue Cross for Commercial. |
Yes |
No |
B4149 |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4150 |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4152 |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4153 |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4154 |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4155 |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4157 |
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4158 |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4159 |
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4160 |
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4161 |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B4162 |
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B9002 |
Enteral nutrition infusion pump - any type |
Other services: enteral feeding and supplies |
Special nutrient formula |
|
Yes |
Yes |
B9998 |
NOC for enteral supplies |
Other services: enteral feeding and supplies |
DME supplies |
|
Yes |
Yes |
C1764 |
Event recorder, cardiac (implantable) |
DME: implant |
DME Implant |
|
Yes |
Yes |
C1767 |
Generator, neurostimulator (implantable), non-rechargeable |
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
C1772 |
Infusion pump, programmable (implantable) |
DME: implant |
DME pump |
|
Yes |
Yes |
C1778 |
Lead, neurostimulator (implantable) |
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
C1783 |
Ocular implant, aqueous drainage assist device |
DME: prosthetic appliances and implants |
Prosthetic devices |
Facility code requires preauthorization |
Yes |
Yes |
C1787 |
Patient programmer neurostimulator |
DME: prosthetic appliances and implants |
Nerve stimulator |
Facility code requires preauthorization |
Yes |
Yes |
C1789 |
Prosthesis, breast (implantable) |
Reconstructive or cosmetic services - breast procedures |
Surgery - breast |
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 1 Applies to Fully Insured products |
Yes |
Yes |
C8922 |
Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8923 |
Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, complete, without SPECTRAL or color doppler echocardiography |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8924 |
Transthoracic echocardiography (TEE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording when performed, follow-up or limited study |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8925 |
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without m-mode recording); including probe placement, image acquisition, interpretation and report |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8926 |
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8927 |
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for monitoring purposes, including probe placement, real time (2D) image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8928 |
Transthoracic echocardiography (TTE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8929 |
Transthoracic echocardiography (TTE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8930 |
Transthoracic echocardiography (TTE) with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision |
Diagnostic services: Cardiac testing |
X-Ray/Imaging - Cardiac studies |
this service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization 1 Applies to Fully Insured products |
Yes |
Yes |
C8931 |
Magnetic Resonance Angiography with contrast, spinal canal and contents |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization |
Yes |
Yes |
C8932 |
Magnetic resonance angiography without contrast, spinal canal and contents |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization |
Yes |
Yes |
C8933 |
Magnetic Resonance Angiography without contrast followed by with contrast, spinal canal and contents |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization |
Yes |
Yes |
C8934 |
Magnetic Resonance Angiography with contrast, upper extremity |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization |
Yes |
Yes |
C8935 |
Magnetic Resonance Angiography without contrast, upper extremity |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
This service is preauthorized through National Imaging Associates (NIA). -Traditional Products do not require preauthorization |
Yes |
Yes |
C8936 |
Magnetic Resonance Angiography without contrast followed by with contrast, upper extremity |
Diagnostic services: MRA |
X-Ray/Imaging - MRA |
This service is preauthorized through National Imaging Associates (NIA). - Traditional Products do not require preauthorization |
Yes |
Yes |
C9069 |
Injection, belantamab 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 |
C9090 |
Injection, plasminogen, human-tvmh, 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 |
C9091 |
Injection, sirolimus 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 |
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 |