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Radiology - Advanced Imaging 2Cardiology 11Interventional Pain 18Spine Surgery 22Joint Services (Hip/Knee/Shoulder) 37Radiation Therapy 50Lab Management 55Medical Oncology - Medicare 66Medical Oncology - Commercial 72
Network Health Plan WIComprehensive Code List
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
BMRI 77046 Magnetic resonance imaging, breast, without contrast material; unilateral Yes YesBMRI 77047 Magnetic resonance imaging, breast, without contrast material; bilateral Yes Yes
BMRI 77048Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral
Yes Yes
BMRI 77049Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral
Yes Yes
CT 70450 Computed tomography, head or brain; without contrast material Yes Yes 70450, 70460, 70470
CT 70460 Computed tomography, head or brain; with contrast material(s) Yes Yes 70450, 70460, 70470
CT 70470 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections Yes Yes 70450, 70460, 70470
CT 70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Yes Yes 70480, 70481, 70482
CT 70481 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) Yes Yes 70480, 70481, 70482
CT 70482 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections Yes Yes 70480, 70481, 70482
CT 70486 Computed tomography, maxillofacial area; without contrast material Yes Yes 70486, 70487, 70488, 76380
CT 70487 Computed tomography, maxillofacial area; with contrast material(s) Yes Yes 70486, 70487, 70488, 76380
CT 70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections Yes Yes 70486, 70487, 70488,
76380
CT 70490 Computed tomography, soft tissue neck; without contrast material Yes Yes 70490, 70491, 70492, 72125, 72126, 72127
Network Health Plan WI Prior Authorization Procedure List: Radiology - Advanced Imaging
*C-CODES APPLY TO MEDICARE MEMBERSHIP ONLY
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
CT 70491 Computed tomography, soft tissue neck; with contrast material(s) Yes Yes 70490, 70491, 70492, 72125, 72126, 72127
CT 70492 Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections Yes Yes 70490, 70491, 70492,
72125, 72126, 72127
CT 70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 70496
CT 70498 Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 70498
CT 71250 Computed tomography, thorax; without contrast material Yes Yes71250, 71260, 71270, 72192, 72193, 72194, 74150, 74160, 74170
CT 71260 Computed tomography, thorax; with contrast material(s) Yes Yes71250, 71260, 71270, 72192, 72193, 72194, 74150, 74160, 74170
CT 71270 Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections Yes Yes
71250, 71260, 71270, 72192, 72193, 72194, 74150, 74160, 74170
CT 71275 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 71275
CT 71550 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) Yes Yes 71550, 71551, 71552
CT 71551 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) Yes Yes 71550, 71551, 71552
CT 71552Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences
Yes Yes 71550, 71551, 71552
CT 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) Yes Yes 71555, C8909, C8910,
C8911
CT 72125 Computed tomography, cervical spine; without contrast material Yes Yes 72125, 72126, 72127, 70490, 70491, 70492
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
CT 72126 Computed tomography, cervical spine; with contrast material Yes Yes 72125, 72126, 72127, 70490, 70491, 70492
CT 72127 Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections Yes Yes 72125, 72126, 72127,
70490, 70491, 70492
CT 72128 Computed tomography, thoracic spine; without contrast material Yes Yes 72128, 72129, 72130
CT 72129 Computed tomography, thoracic spine; with contrast material Yes Yes 72128, 72129, 72130
CT 72130 Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections Yes Yes 72128, 72129, 72130
CT 72131 Computed tomography, lumbar spine; without contrast material Yes Yes 72131, 72132, 72133
CT 72132 Computed tomography, lumbar spine; with contrast material Yes Yes 72131, 72132, 72133
CT 72133 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections Yes Yes 72131, 72132, 72133
CT 72191 Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 72191
CT 72192 Computed tomography, pelvis; without contrast material Yes Yes
72192, 72193,72194, 71250,71260, 71270,74150, 74160,
74170
CT 72193 Computed tomography, pelvis; with contrast material(s) Yes Yes
72192, 72193,72194, 71250,71260, 71270,74150, 74160,
74170
CT 72194 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections Yes Yes
72192, 72193,72194, 71250,71260, 71270,74150, 74160,
74170
CT 73200 Computed tomography, upper extremity; without contrast material Yes Yes 73200, 73201,73202
CT 73201 Computed tomography, upper extremity; with contrast material(s) Yes Yes 73200, 73201,73202
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
CT 73202 Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections Yes Yes 73200, 73201,
73202
CT 73206 Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 73206
CT 73700 Computed tomography, lower extremity; without contrast material Yes Yes 73700, 73701, 73702
CT 73701 Computed tomography, lower extremity; with contrast material(s) Yes Yes 73700, 73701, 73702
CT 73702 Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections Yes Yes 73700, 73701, 73702
CT 73706 Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 73706
CT 74150 Computed tomography, abdomen; without contrast material Yes Yes
74150, 74160,74170, 71250,71260, 71270,72192, 72193,
72194
CT 74160 Computed tomography, abdomen; with contrast material(s) Yes Yes
74150, 74160,74170, 71250,71260, 71270,72192, 72193,
72194
CT 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections Yes Yes
74150, 74160,74170, 71250,71260, 71270,72192, 72193,
72194
CT 74174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 74174
CT 74175 Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 74175
CT 74176 Computed tomography, abdomen and pelvis; without contrast material Yes Yes 74176, 74177,74178
CT 74177 Computed tomography, abdomen and pelvis; with contrast material(s) Yes Yes 74176, 74177,74178
CT 74178 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions Yes Yes 74176, 74177,
74178
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
CT 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Yes Yes 74261, 74262
CT 74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed Yes Yes 74261, 74262
CT 74263 Computed tomographic (CT) colonography, screening, including image postprocessing Yes Yes 74263
CT 75635Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Yes Yes 75635
CT 76380 Computed tomography, limited or localized follow-up study Yes Yes 76380, 70486,70487, 70488
CT 76497 Unlisted computed tomography procedure (eg, diagnostic, interventional) Yes Yes 76497
CT G0297 Low-dose CT For Lung Cancer Screening Yes Yes G0297, 70486,70487, 70488
CT S8092 CT Electron Beam (also known as Ultrafast CT, Cine CT), for calcium scoring Yes Yes S8092MR 70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) Yes Yes 70336
MR 70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) Yes Yes 72141, 72142, 72156,
70540, 70542, 70543
MR 70542 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) Yes Yes 70551, 70552, 70553, 70540, 70542, 70543
MR 70543 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 70551, 70552, 70553,
70540, 70542, 70543,
MR 70544 Magnetic resonance angiography, head; without contrast material(s) Yes Yes 70544, 70545, 70546
MR 70545 Magnetic resonance angiography, head; with contrast material(s) Yes Yes 70544, 70545, 70546
MR 70546 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 70544, 70545, 70546
MR 70547 Magnetic resonance angiography, neck; without contrast material(s) Yes Yes 70547, 70548, 70549
MR 70548 Magnetic resonance angiography, neck; with contrast material(s) Yes Yes 70547, 70548, 70549
MR 70549 Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 70547, 70548, 70549
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
MR 70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material Yes Yes 70551, 70552, 70553,
70540, 70542, 70543
MR 70552 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) Yes Yes 70551, 70552, 70553,
70540, 70542, 70543
MR 70553 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences Yes Yes 70551, 70552, 70553,
70540, 70542, 70543
MR 70554Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
Yes Yes 70554, 70555
MR 70555 Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing Yes Yes 70554, 70555
MR 72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material Yes Yes 72141, 72142, 72156,
70540, 70542, 70543
MR 72142 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) Yes Yes 72141, 72142, 72156,
70540, 70542, 70543
MR 72146 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material Yes Yes 72146, 72147, 72157
MR 72147 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) Yes Yes 72146, 72147, 72157
MR 72148 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material Yes Yes 72148, 72149, 72158
MR 72149 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) Yes Yes 72148, 72149, 72158
MR 72156 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical Yes Yes 72156, 70540, 70542,
70543, 72141, 72142
MR 72157 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic Yes Yes 72157, 72146, 72147
MR 72158 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar Yes Yes 72158, 72148, 72149
MR 72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) Yes Yes 72159, C8931,
C8932, C8933
MR 72195 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) Yes Yes 72195, 72196, 72197
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
MR 72196 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) Yes Yes 72195, 72196,72197
MR 72197 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 72195, 72196, 72197
MR 72198 Magnetic resonance angiography, pelvis, with or without contrast material(s) Yes Yes 72198, C8918,C8919, C8920
MR 73218 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) Yes Yes 73218, 73219, 73220
MR 73219 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) Yes Yes 73218, 73219, 73220
MR 73220 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 73218, 73219,
73220
MR 73221 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) Yes Yes 73221, 73222,
73223
MR 73222 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Yes Yes 73221, 73222,
73223
MR 73223 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 73221, 73222,
73223
MR 73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s) Yes Yes 73225, C8934,C8935, C8936
MR 73718 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Yes Yes
73718, 73719,73720, 73721,73722, 73723
MR 73719 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) Yes Yes
73718, 73719,73720, 73721,73722, 73723
MR 73720 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes
73718, 73719,73720, 73721,73722, 73723
MR 73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Yes Yes
73721, 73722,73723, 73718,73719, 73720,72195, 72196,
72197
MR 73722 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) Yes Yes
73718, 73719,73720, 73721,73722, 73723
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
MR 73723 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes
73718, 73719,73720, 73721,73722, 73723
MR 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) Yes Yes 73725, C8912,C8913, C8914
MR 74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) Yes Yes 74181, 74182,74183, S8037
MR 74182 Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) Yes Yes 74181, 74182,74183, S8037
MR 74183 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences Yes Yes 74181, 74182, 74183,
S8092
MR 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) Yes Yes 74185, C8900,C8901, C8902
MR 74712 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation Yes Yes 74712, 78491,
78492, 74713
MR 74713Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)
Yes Yes 74713, 78491,78492, 74712
MR 76390 Magnetic resonance spectroscopy Yes Yes 76390MR 76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional) Yes Yes 76498
MR 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral Yes Yes
77058, 77059,C8903, C8904,C8905, C8906,C8907, C8908
MR 77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral Yes Yes
77059, 77059,C8903, C8904,C8905, C8906,C8907, C8908
MR 77084 Magnetic resonance (eg, proton) imaging, bone marrow blood supply Yes Yes 77084MR S8035 Magnetic Source Imaging (MSI) Yes Yes S8035
MR S8037 Magnetic resonance cholangiopancreatography (MRCP) Yes Yes S8037, 74181,74182, 74183
MR S8042 MRI Low Field Yes Yes S8042MRI 76391 Magnetic resonance (eg, vibration) elastography Yes Yes
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
MRI C8937 Computer-aided detection, including computer algorithm analysis of breast mri image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation (list separately in addition to code for primary procedure)
No Yes
PET 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation Yes Yes 78459, 78491,78492
PET 78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress Yes Yes 78459, 78491,
78492
PET 78492 Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress Yes Yes 78459, 78491,
78492PET 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation Yes Yes 78608, 78609PET 78609 Brain imaging, positron emission tomography (PET); perfusion evaluation Yes Yes 78609, 78609
PET 78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) Yes Yes78811, 78812,78813, 78814,78815, 78816
PET 78812 Positron emission tomography (PET) imaging; skull base to mid-thigh Yes Yes78811, 78812,78813, 78814,78815, 78816
PET 78813 Positron emission tomography (PET) imaging; whole body Yes Yes78811, 78812,78813, 78814,78815, 78816
PET 78814Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
Yes Yes78811, 78812,78813, 78814,78815, 78816
PET 78815 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh Yes Yes
78811, 78812,78813, 78814,78815, 78816
PET 78816 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body Yes Yes
78811, 78812,78813, 78814,78815, 78816,
G0219CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
V1.2019 Effective: 7/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Catheterization 93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed Yes No 93451
Catheterization 93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Yes No 93452
Catheterization 93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Yes No 93453
Catheterization 93454Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Catheterization 93455
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Catheterization 93456Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Catheterization 93457
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Catheterization 93458
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Network Health Plan WIPrior Authorization Procedure List: Cardiology
*C-CODES APPLY TO MEDICARE MEMBERSHIP ONLY
V1.2019 Effective: 7/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Catheterization 93459
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Catheterization 93460
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Catheterization 93461
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461
Catheterization 93530 Right heart catheterization, for congenital cardiac anomalies Yes No 93530
Catheterization 93531 Combined right heart catheterization and retrograde left heart catheterization, for congenital cardiac anomalies Yes No 93531
Catheterization 93532Combined right heart catheterization and transseptal left heart catheterization through intact septum with or without retrograde left heart catheterization, for congenital cardiac anomalies
Yes No 93532
Catheterization 93533Combined right heart catheterization and transseptal left heart catheterization through existing septal opening, with or without retrograde left heart catheterization, for congenital cardiac anomalies
Yes No 93533
CT 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium Yes No 75571
CT 75572Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
Yes No 75572
CT 75573
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)
Yes No 75573
V1.2019 Effective: 7/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
CT 75574
Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
Yes No 75574
CT 0501T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordantdata, interpretation and report
Yes No
CT 0502T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission
Yes No
CT 0503T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model
Yes No
CT 0504T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report
Yes No
Echo 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete Yes No 93303, 93304, +93320, +93321, +93325
Echo 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Yes No 93303, 93304, +93320,
+93321, +93325
Echo 93306Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography
Yes No 93306, 93307, 93308, C8924
V1.2019 Effective: 7/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Echo 93307Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography
Yes No 93306, 93307, 93308, C8924
Echo 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Yes No 93306, 93307, 93308,
+93321, +93325
Echo 93312Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report
Yes No 93312, 93313, 99314, +93320, +93321, +93325
Echo 93313 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only Yes No 93312, 93313, 99314,
+93320, +93321, +93325
Echo 93314 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only Yes No 93312, 93313, 99314,
+93320, +93321, +93325
Echo 93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Yes No 93315, 93316, 93317,
+93320, +93321, +93325
Echo 93316 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only Yes No 93315, 93316, 93317,
+93320, +93321, +93325
Echo 93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only Yes No 93315, 93316, 93317,
+93320, +93321, +93325
Echo 93318
Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis
Yes No 93318
Echo 93320Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete
Yes No add on code, must be billed with another code
Echo 93321
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging)
Yes No add on code, must be billed with another code
Echo 93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) Yes No add on code, must be billed
with another code
Echo 93350
Echocardiography, transthoracic, 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;
Yes No 93350, 93351, +93320, +93321, +93325
V1.2019 Effective: 7/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Echo 93351
Echocardiography, transthoracic, 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 supervision by a physician or other qualified health care professional
Yes No 93350, 93351, +93320, +93321, +93325
MR 75557 Cardiac magnetic resonance imaging for morphology and function without contrast material; Yes No
75557, 75559,75561, 75563,
+75565
MR 75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging Yes No
75557, 75559,75561, 75563,
+75565
MR 75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; Yes No
75557, 75559,75561, 75563,
+75565
MR 75563Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging
Yes No75557, 75559,75561, 75563,
+75565
MR 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Yes No
75557, 75559,75561, 75563,
+75565Nuc Card 78414 Non-Imaging Heart Function Yes NoNuc Card 78428 Cardiac Shunt Imaging Yes No
Nuc Card 78451
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78452
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78453Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
V1.2019 Effective: 7/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Nuc Card 78454
Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78468 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique Yes No
78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification Yes No
78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78472Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing
Yes No 78472, 78473, 78494, +78496
Nuc Card 78473Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification
Yes No 78472, 78473, 78494, +78496
Nuc Card 78481Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78483Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,
78483, 78499
Nuc Card 78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing Yes No 78472, 78473, 78494,
+78496
Nuc Card 78496Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure)
Yes No 78472, 78473, 78494, +78496
Nuc Card 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine Yes No 78499
V1.2019 Effective: 7/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
PET 0482T Absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (list separately in addition to code for primary procedure) Yes No
CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Internventional Pain 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance
(fluoroscopy or CT) including arthrography when performed Yes Yes 27096
Internventional Pain 62263
Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
Yes Yes 62263, 62264
Internventional Pain 62264
Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day
Yes Yes 62263, 62264
Internventional Pain 62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline
solutions), with or without other therapeutic substance; subarachnoid Yes Yes 62280, 62281, 62282
Internventional Pain 62281
Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic
Yes Yes 62280, 62281, 62282
Internventional Pain 62282
Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)
Yes Yes 62280, 62281, 62282
Internventional Pain 62320
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Internventional Pain 62321
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Network Health Plan WIPrior Authorization Procedure List: Interventional Pain
*C-CODES APPLY TO MEDICARE MEMBERSHIP ONLY
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Internventional Pain 62322
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Internventional Pain 62323
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Internventional Pain 62324
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Internventional Pain 62325
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Internventional Pain 62326
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Internventional Pain 62327
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327
Internventional Pain 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging
guidance (fluoroscopy or CT); cervical or thoracic, single level Yes Yes 64479, 64480
Internventional Pain 64480
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
Yes Yes 64479, 64480
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Internventional Pain 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging
guidance (fluoroscopy or CT); lumbar or sacral, single level Yes Yes 64483, 64484
Internventional Pain 64484
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
Yes Yes 64483, 64484
Internventional Pain 64490
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
Yes Yes 64490, 64491, 64492, 64493, 64494, 64495
Internventional Pain 64491
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)
Yes Yes 64490, 64491, 64492, 64493, 64494, 64495
Internventional Pain 64492
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
Yes Yes 64490, 64491, 64492, 64493, 64494, 64495
Internventional Pain 64493
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
Yes Yes 64490, 64491, 64492, 64493, 64494, 64495
Internventional Pain 64494
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)
Yes Yes 64490, 64491, 64492, 64493, 64494, 64495
Internventional Pain 64495
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
Yes Yes 64490, 64491, 64492, 64493, 64494, 64495
Internventional Pain 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Yes Yes 64510, 64520
Internventional Pain 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) Yes Yes 64510, 64520
Internventional Pain 64620 Destruction by neurolytic agent, intercostal nerve Yes Yes 64620
Internventional Pain 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging
guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Yes Yes 64633, 64634, 64635, 64636
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Internventional Pain 64634
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
Yes Yes 64633, 64634, 64635, 64636
Internventional Pain 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Yes Yes 64633, 64634, 64635, 64636
Internventional Pain 64636
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
Yes Yes 64633, 64634, 64635, 64636
Internventional Pain 0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
ultrasound guidance, cervical or thoracic; single level Yes Yes 0228T, 0229T, 0230T, 0231T
Internventional Pain 0229T
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)
Yes Yes 0228T, 0229T, 0230T, 0231T
Internventional Pain 0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
ultrasound guidance, lumbar or sacral; single level Yes Yes 0228T, 0229T, 0230T, 0231T
Internventional Pain 0231T
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)
Yes Yes 0228T, 0229T, 0230T, 0231T
Internventional Pain M0076 Prolotherapy Yes Yes M0076
CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
V1.2019 Effective: 7/1/2019
*C-CODES APPLY TO MEDICARE MEMBERSHIP ONLY
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) Yes No 20930, 20931
Spine Surgery 20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) Yes No 20930, 20931
Spine Surgery 20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative) Yes No 20974, 20975, 20979
Spine Surgery 20975 Electrical stimulation to aid bone healing; invasive (operative) Yes No 20974, 20975, 20979
Spine Surgery 20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) Yes No 20974, 20975, 20979
Spine Surgery 22100 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical Yes No 22100, 22101, 22103,
22110, 22112, 22116
Spine Surgery 22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic Yes No
22100, 22101, 22103, 22110, 22112, 22114,
22116
Spine Surgery 22102 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar Yes No 22101, 22102, 22103,
22112, 22114, 22116
Spine Surgery 22103Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure)
Yes No22100, 22101, 22103, 22110, 22112, 22114,
22116
Spine Surgery 22110 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical Yes No 22100, 22101, 22103,
22110, 22112, 22116
Spine Surgery 22112 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic Yes No
22100, 22101, 22103, 22110, 22112, 22114,
22116
Spine Surgery 22114 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar Yes No 22101, 22102, 22103,
22112, 22114, 22116
Network Health Plan WI - Prior Authorization Procedure List: Spine Surgery
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 22116Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)
Yes No22100, 22101, 22103, 22110, 22112, 22114,
22116
Spine Surgery 22206 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic Yes No
22206, 22207, 22208, 22210, 22212, 22214,
22216
Spine Surgery 22207 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar Yes No 22206, 22207, 22208,
22212, 22214, 22216
Spine Surgery 22208Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure)
Yes No22206, 22207, 22208, 22210, 22212, 22214,
22216
Spine Surgery 22210 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical Yes No 22206, 22208, 22210,
22212, 22214, 22216
Spine Surgery 22212 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic Yes No
22206, 22207, 22208, 22210, 22212, 22214,
22216
Spine Surgery 22214 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar Yes No 22206, 22207, 22208,
22212, 22214, 22216
Spine Surgery 22216 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) Yes No
22206, 22207, 22208, 22210, 22212, 22214,
22216
Spine Surgery 22220 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical Yes No 22220, 22222, 22226
Spine Surgery 22222 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic Yes No 22220, 22222, 22224,
22226
Spine Surgery 22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar Yes No 22222, 22224, 22226
Spine Surgery 22226Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)
Yes No 22220, 22222, 22224, 22226
Spine Surgery 22505 Manipulation of spine requiring anesthesia, any region Yes No 22505
Spine Surgery 22510Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
Yes No 22510, 22511, 22512, 22513, 22514, 22515
Spine Surgery 22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral Yes No 22510, 22511, 22512,
22513, 22514, 22515
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 22512
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)
Yes No 22510, 22511, 22512, 22513, 22514, 22515
Spine Surgery 22513
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic
Yes No 22510, 22511, 22512, 22513, 22514, 22515
Spine Surgery 22514
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar
Yes No 22510, 22511, 22512, 22513, 22514, 22515
Spine Surgery 22515
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)
Yes No 22510, 22511, 22512, 22513, 22514, 22515
Spine Surgery 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level Yes No
22520, 22521, 22522, 22523, 22524, 22525,
22526, 22527
Spine Surgery 22527Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)
Yes No22520, 22521, 22522, 22523, 22524, 22525,
22526, 22527
Spine Surgery 22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic Yes No 22532, 22533, 22534
Spine Surgery 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Yes No 22532, 22533, 22534
Spine Surgery 22534Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)
Yes No 22532, 22533, 22534
Spine Surgery 22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process Yes No 22548, 22551, 22552,
22554, 22556, 22585
Spine Surgery 22551Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
Yes No 22548, 22551, 22552, 22554, 22556, 22585
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 22552
Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)
Yes No22548, 22551, 22552, 22554, 22556, 22585,
22558
Spine Surgery 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 Yes No 22548, 22551, 22552,
22554, 22556, 22585
Spine Surgery 22556 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic Yes No
22548, 22551, 22552, 22554, 22556, 22585,
22558
Spine Surgery 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Yes No 22552, 22556, 22558,
22585
Spine Surgery 22585Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
Yes No22548, 22551, 22552, 22554, 22556, 22585,
22558
Spine Surgery 22586Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace
Yes No 22586
Spine Surgery 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) Yes No22590, 22595, 22600, 22610, 22614, 22632,
22634
Spine Surgery 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) Yes No22590, 22595, 22600, 22610, 22614, 22632,
22634
Spine Surgery 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment Yes No
22590, 22595, 22600, 22610, 22614, 22632,
22634
Spine Surgery 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) Yes No
22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,
22634
Spine Surgery 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) Yes No
22610, 22612, 22614, 22630, 22632, 22633,
22634
Spine Surgery 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) Yes No
22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,
22634
Spine Surgery 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Yes No
22610, 22612, 22614, 22630, 22632, 22633,
22634
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 22632Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)
Yes No
22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,
22634
Spine Surgery 22633Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
Yes No22610, 22612, 22614, 22630, 22632, 22633,
22634
Spine Surgery 22634
Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)
Yes No
22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,
22634
Spine Surgery 22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments Yes No 22800, 22802, 22804
Spine Surgery 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments Yes No 22800, 22802, 22804
Spine Surgery 22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments Yes No 22800, 22802, 22804
Spine Surgery 22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments Yes No 22808, 22810, 22812
Spine Surgery 22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments Yes No 22808, 22810, 22812
Spine Surgery 22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments Yes No 22808, 22810, 22812
Spine Surgery 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments Yes No 22818, 22819
Spine Surgery 22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments Yes No 22818, 22819
Spine Surgery 22830 Exploration of spinal fusion Yes No 22830
Spine Surgery 22840
Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
Yes No 22840, 22841, 22842, 22843, 22844
Spine Surgery 22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Yes No 22840, 22841, 22842,
22843, 22844
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 22842Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
Yes No 22840, 22841, 22842, 22843, 22844
Spine Surgery 22843Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)
Yes No 22840, 22841, 22842, 22843, 22844
Spine Surgery 22844Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)
Yes No 22840, 22841, 22842, 22843, 22844
Spine Surgery 22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) Yes No 22845, 22846, 22847
Spine Surgery 22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) Yes No 22845, 22846, 22847
Spine Surgery 22847 Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) Yes No 22845, 22846, 22847
Spine Surgery 22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) Yes No 22848
Spine Surgery 22849 Reinsertion of spinal fixation device Yes No 22849
Spine Surgery 22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) Yes No 22850
Spine Surgery 22853
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when conjunction with interbody arthrodesis, each interspace (List performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)
Yes No 22853, 22854, 22859
Spine Surgery 22854
Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
Yes No 22853, 22854, 22859
Spine Surgery 22856Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical
Yes No 22856, 22858 22861
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar Yes No 22857, 22862
Spine Surgery 22858
Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)
Yes No 22856, 22858 22861
Spine Surgery 22859
Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous efect (List separately in addition to code for primary procedure)
Yes No 22853, 22854, 22859
Spine Surgery 22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical Yes No 22856,22858, 22861
Spine Surgery 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar Yes No 22857, 22862
Spine Surgery 22867Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
Yes No 22867, 22868, 22869, 22870
Spine Surgery 22868Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)
Yes No 22867, 22868, 22869, 22870
Spine Surgery 22869Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level
Yes No 22867, 22868, 22869, 22870
Spine Surgery 22870Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)
Yes No 22867, 22868, 22869, 22870
Spine Surgery 27279Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device
Yes No 27279, 27280, 27282, 27284, 27286
Spine Surgery 27280 Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed Yes No 27279, 27280, 27282,
27284, 27286
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 62287
Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
Yes No 62287
Spine Surgery 62292 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar Yes No 62292
Spine Surgery 62350Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy
Yes No 62350, 62351
Spine Surgery 62351Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy
Yes No 62350, 62351
Spine Surgery 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Yes No 62360, 62361, 62362
Spine Surgery 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump Yes No 62360, 62361, 62362
Spine Surgery 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Yes No 62360, 62361, 62362
Spine Surgery 62380Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar
Yes No 62380
Spine Surgery 63001Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical
Yes No 63001, 63003, 63015, 63016
Spine Surgery 63003Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic
Yes No63001, 63003, 63005, 63012, 63015, 63016,
63017
Spine Surgery 63005Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis
Yes No 63003, 63005, 63011, 63012, 63016, 63017
Spine Surgery 63011Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral
Yes No 63005, 63011, 63012, 63016, 63017
Spine Surgery 63012Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)
Yes No 63003, 63005, 63011, 63012, 63016, 63017
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 63015Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical
Yes No 63001, 63003, 63015, 63016
Spine Surgery 63016Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic
Yes No63001, 63003, 63005, 63012, 63015, 63016,
63017
Spine Surgery 63017Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar
Yes No 63003, 63005, 63011, 63012, 63016, 63017
Spine Surgery 63020Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical
Yes No 63020, 63035, 63040, 63043
Spine Surgery 63030Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
Yes No 63030, 63035, 63042, 63044
Spine Surgery 63035
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)
Yes No63020, 63030, 63035, 63040, 63042, 63043,
63044
Spine Surgery 63040Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical
Yes No 63020, 63035, 63043
Spine Surgery 63042Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar
Yes No 63030, 63035, 63042, 63044
Spine Surgery 63043
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)
Yes No 63020, 63035, 63040, 63043
Spine Surgery 63044
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)
Yes No 63030, 63035, 63042, 63044
Spine Surgery 63045Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical
Yes No 63045, 63046, 63048
Spine Surgery 63046Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic
Yes No 63045, 63046, 63047, 63048
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 63047Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
Yes No 63046, 63047, 63048
Spine Surgery 63048
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)
Yes No 63045, 63046, 63047, 63048
Spine Surgery 63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; Yes No 63050, 63051
Spine Surgery 63051
Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)
Yes No 63050, 63051
Spine Surgery 63055 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic Yes No 63055, 63056, 63057
Spine Surgery 63056
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)
Yes No 63055, 63056, 63057
Spine Surgery 63057Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)
Yes No 63055, 63056, 63057
Spine Surgery 63064 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment Yes No 63064, 63066
Spine Surgery 63066Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary procedure)
Yes No 63064, 63066
Spine Surgery 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace Yes No 63075, 63076, 63077,
63078
Spine Surgery 63076Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)
Yes No 63075, 63076, 63077, 63078
Spine Surgery 63077 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace Yes No 63075, 63076, 63077,
63078
Spine Surgery 63078Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure)
Yes No 63075, 63076, 63077, 63078
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 63081Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment
Yes No 63081, 63082
Spine Surgery 63082Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure)
Yes No 63081, 63082
Spine Surgery 63085Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment
Yes No 63085, 63086
Spine Surgery 63086Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure)
Yes No 63085, 63086
Spine Surgery 63087Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment
Yes No 63087, 63088
Spine Surgery 63088
Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure)
Yes No 63087, 63088
Spine Surgery 63090Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment
Yes No 63090, 63091
Spine Surgery 63091
Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure)
Yes No 63090, 63091
Spine Surgery 63101Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment
Yes No 63101, 63102, 63103
Spine Surgery 63102Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment
Yes No 63101, 63102, 63103
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 63103
Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure)
Yes No 63101, 63102, 63103
Spine Surgery 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar Yes No 63170
Spine Surgery 63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments Yes No 63180, 63182
Spine Surgery 63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments Yes No 63180, 63182
Spine Surgery 63185 Laminectomy with rhizotomy; 1 or 2 segments Yes No 63185, 63190, 63295
Spine Surgery 63190 Laminectomy with rhizotomy; more than 2 segments Yes No 63185, 63190, 63295
Spine Surgery 63191 Laminectomy with section of spinal accessory nerve Yes No 63191
Spine Surgery 63295 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) Yes No
63172, 63173, 63185, 63190, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287,
63290, 63295
Spine Surgery 63650 Percutaneous implantation of neurostimulator electrode array, epidural Yes No 63650
Spine Surgery 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Yes No 63655
Spine Surgery 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Yes No 63663
Spine Surgery 63664Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
Yes No 63664
Spine Surgery 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Yes No 63685
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver Yes No 63688
Spine Surgery 0163TTotal disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (List separately in addition to code for primary procedure)
Yes No 0163T
Spine Surgery 0164T Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) Yes No 0164T
Spine Surgery 0165TRevision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)
Yes No 0165T
Spine Surgery 0200TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed
Yes No 0200T, 0201T
Spine Surgery 0201TPercutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed
Yes No 0200T, 0201T
Spine Surgery 0202TPosterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine
Yes No 0202T
Spine Surgery 0213TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
Spine Surgery 0214TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)
Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
Spine Surgery 0215T
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
Spine Surgery 0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
Spine Surgery 0217TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)
Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery 0218T
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
Spine Surgery 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical Yes No 0219T, 0220T, 0222T
Spine Surgery 0220T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic Yes No 0219T, 0220T, 0222T
Spine Surgery 0221T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar Yes No 0221T, 0220T, 0222T
Spine Surgery 0222T
Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure)
Yes No 0219T, 0220T, 0221T, 0222T
Spine Surgery 0275T
Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar
Yes No 0275T
Spine Surgery C1767 Generator, neurostimulator (implantable), nonrechargeable No No C1767
Spine Surgery C1778 Lead, neurostimulator (implantable) No No C1778
Spine Surgery C1787 Patient programmer, neurostimulator No No C1787
Spine Surgery C1816 Receiver and/or transmitter, neurostimulator (implantable) No No C1816
Spine Surgery C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system No No C1820
Spine Surgery C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) No No C1883
Spine Surgery C1897 Lead, neurostimulator test kit (implantable) No No C1897
Spine Surgery E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications Yes No E0748
V1.2019 Effective: 7/1/2019
Category CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Spine Surgery E0749 Osteogenesis stimulator, electrical, surgically implanted Yes No E0749
Spine Surgery E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive Yes No E0760
Spine Surgery L8680 Implantable neurostimulator electrode, each Yes No L8680
Spine Surgery L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only Yes No L8681
Spine Surgery L8682 Implantable neurostimulator radiofrequency receiver Yes No L8682
Spine Surgery L8683 Radio frequency transmitter (external) for use with implantable neurostimulator radio frequency receiver Yes No L8683
Spine Surgery L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension Yes No L8685
Spine Surgery L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension Yes No L8686
Spine Surgery L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension Yes No L8687
Spine Surgery L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension Yes No L8688
Spine Surgery L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only Yes No L8689
Spine Surgery L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only Yes No L8695
Spine Surgery S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar Yes No S2348
Spine Surgery S2350 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace Yes No S2350, S2351
Spine Surgery S2351Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, each additional interspace (List separately in addition to code for primary procedure)
Yes No S2350, S2351
CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 23000 Removal of subdeltoid calcareous deposits, open Yes Yes 23000, 23020
Joint Surgery 23020 Capsular contracture release (eg, Sever type procedure) Yes Yes 23000, 23020
Joint Surgery 23100 Arthrotomy, glenohumeral joint, including biopsy Yes Yes 23100, 23101, 23105, 23106, 23107
Joint Surgery 23101 Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage Yes Yes 23100, 23101, 23105, 23106,
23107
Joint Surgery 23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy Yes Yes 23100, 23101, 23105, 23106, 23107
Joint Surgery 23106 Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy Yes Yes 23100, 23101, 23105, 23106, 23107
Joint Surgery 23107 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body Yes Yes 23100, 23101, 23105, 23106,
23107
Joint Surgery 23120 Claviculectomy; partial Yes Yes 23120
Joint Surgery 23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release Yes Yes 23130
Joint Surgery 23190 Ostectomy of scapula, partial (eg, superior medial angle) Yes Yes 23190
Joint Surgery 23395 Muscle transfer, any type, shoulder or upper arm; single Yes Yes 23395, 23397, 23430, 23440
Joint Surgery 23397 Muscle transfer, any type, shoulder or upper arm; multiple Yes Yes 23395, 23397, 23430, 23440
Network Health Plan WIPrior Authorization Procedure List: Joint Services (Hip/Knee/Shoulder)
*C-CODES APPLY TO MEDICARE MEMBERSHIP ONLY
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 23405 Tenotomy, shoulder area; single tendon Yes Yes 23405, 23406
Joint Surgery 23406 Tenotomy, shoulder area; multiple tendons through same incision Yes Yes 23405, 23406
Joint Surgery 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute Yes Yes 23410, 23412
Joint Surgery 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic Yes Yes 23410, 23412
Joint Surgery 23415 Coracoacromial ligament release, with or without acromioplasty Yes Yes 23415, 23420
Joint Surgery 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Yes Yes
23395, 23397, 23405, 23406, 23410, 23412, 23415, 23420,
23430, 23440
Joint Surgery 23430 Tenodesis of long tendon of biceps Yes Yes 23395, 23397, 23430, 23440
Joint Surgery 23440 Resection or transplantation of long tendon of biceps Yes Yes 23395, 23397, 23430, 23440
Joint Surgery 23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation Yes Yes 23450, 23455, 23460, 23462, 23465, 23466
Joint Surgery 23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) Yes Yes 23450, 23455, 23460, 23462, 23465, 23466
Joint Surgery 23460 Capsulorrhaphy, anterior, any type; with bone block Yes Yes 23450, 23455, 23460, 23462, 23465, 23466
Joint Surgery 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer Yes Yes 23450, 23455, 23460, 23462, 23465, 23466
Joint Surgery 23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block Yes Yes 23450, 23455, 23460, 23462, 23465, 23470
Joint Surgery 23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability Yes Yes 23450, 23455, 23460, 23462, 23465, 23470
Joint Surgery 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty Yes Yes 23470, 23472
Joint Surgery 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Yes Yes 23470, 23472
Joint Surgery 23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component Yes Yes 23473, 23472
Joint Surgery 23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component Yes Yes 23473, 23472
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 23480 Osteotomy, clavicle, with or without internal fixation; Yes Yes 23480
Joint Surgery 23800 Arthrodesis, glenohumeral joint; Yes Yes 23800, 23802
Joint Surgery 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) Yes Yes 23800, 23802
Joint Surgery 27033 Arthrotomy, hip, including exploration or removal of loose or foreign body Yes Yes 27033
Joint Surgery 27035 Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves Yes Yes 27035
Joint Surgery 27036Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas)
Yes Yes 27036
Joint Surgery 27050 Arthrotomy, with biopsy; sacroiliac joint Yes Yes 27050, 27052, 27054
Joint Surgery 27052 Arthrotomy, with biopsy; hip joint Yes Yes 27050, 27052, 27054
Joint Surgery 27054 Arthrotomy with synovectomy, hip joint Yes Yes 27050, 27052, 27054
Joint Surgery 27060 Excision; ischial bursa Yes Yes 27060, 27062,
Joint Surgery 27062 Excision; trochanteric bursa or calcification Yes Yes 27060, 27062,
Joint Surgery 27080 Coccygectomy, primary Yes Yes 27080
Joint Surgery 27090 Removal of hip prosthesis; (separate procedure) Yes Yes 27090, 27091
Joint Surgery 27091 Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer Yes Yes 27090, 27091
Joint Surgery 27122 Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) Yes Yes 27122, 27125, 27130
Joint Surgery 27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) Yes Yes 27122, 27125, 27130
Joint Surgery 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft Yes Yes 27122, 27125, 27130
Joint Surgery 27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft Yes Yes 27132
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft Yes Yes 27134, 27137, 27138
Joint Surgery 27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft Yes Yes 27134, 27137, 27138
Joint Surgery 27138 Revision of total hip arthroplasty; femoral component only, with or without allograft Yes Yes 27134, 27137, 27138
Joint Surgery 27140 Osteotomy and transfer of greater trochanter of femur (separate procedure) Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165
Joint Surgery 27146 Osteotomy, iliac, acetabular or innominate bone; Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165
Joint Surgery 27147 Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165
Joint Surgery 27151 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165
Joint Surgery 27156 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip Yes Yes 27140, 27146, 27147, 27151,
27156, 27158, 27161, 27165
Joint Surgery 27158 Osteotomy, pelvis, bilateral (eg, congenital malformation) Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165
Joint Surgery 27161 Osteotomy, femoral neck (separate procedure) Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165
Joint Surgery 27165 Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast Yes Yes 27140, 27146, 27147, 27151,
27156, 27158, 27161, 27165
Joint Surgery 27282 Arthrodesis, symphysis pubis (including obtaining graft) Yes Yes 27279, 27280, 27282, 27284, 27286
Joint Surgery 27284 Arthrodesis, hip joint (including obtaining graft); Yes Yes 27279, 27280, 27282, 27284, 27286
Joint Surgery 27286 Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy Yes Yes 27279, 27280, 27282, 27284, 27286
Joint Surgery 27330 Arthrotomy, knee; with synovial biopsy only Yes Yes 27330. 27331, 27332, 27333, 27334, 27335
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 27331 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies Yes Yes 27330. 27331, 27332, 27333,
27334, 27335
Joint Surgery 27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral Yes Yes 27330. 27331, 27332, 27333,
27334, 27335
Joint Surgery 27333 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral Yes Yes 27330. 27331, 27332, 27333,
27334, 27335
Joint Surgery 27334 Arthrotomy, with synovectomy, knee; anterior OR posterior Yes Yes 27330. 27331, 27332, 27333, 27334, 27335
Joint Surgery 27335 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area Yes Yes 27330. 27331, 27332, 27333, 27334, 27335
Joint Surgery 27340 Excision, prepatellar bursa Yes Yes 27340, 23745, 27347
Joint Surgery 27345 Excision of synovial cyst of popliteal space (eg, Baker's cyst) Yes Yes 27340, 23745, 27347
Joint Surgery 27347 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee Yes Yes 27340, 23745, 27347
Joint Surgery 27350 Patellectomy or hemipatellectomy Yes Yes 27350, 27420, 27422, 27424
Joint Surgery 27403 Arthrotomy with meniscus repair, knee Yes Yes 27403
Joint Surgery 27405 Repair, primary, torn ligament and/or capsule, knee; collateral Yes Yes 27405, 27407, 27409
Joint Surgery 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate Yes Yes 27405, 27407, 27409
Joint Surgery 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments Yes Yes 27405, 27407, 27409
Joint Surgery 27412 Autologous chondrocyte implantation, knee Yes Yes 27412, 27415, 27416
Joint Surgery 27415 Osteochondral allograft, knee, open Yes Yes 27412, 27415, 27416
Joint Surgery 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) Yes Yes 27412, 27415, 27416
Joint Surgery 27418 Anterior tibial tubercleplasty (eg, Maquet type procedure) Yes Yes 27418
Joint Surgery 27420 Reconstruction of dislocating patella; (eg, Hauser type procedure) Yes Yes 27350, 27420, 27422, 27424
Joint Surgery 27422 Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) Yes Yes 27350, 27420, 27422, 27424
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 27424 Reconstruction of dislocating patella; with patellectomy Yes Yes 27350, 27420, 27422, 27424
Joint Surgery 27425 Lateral retinacular release, open Yes Yes 27425, 27427, 27428, 27429
Joint Surgery 27427 Ligamentous reconstruction (augmentation), knee; extra-articular Yes Yes 27425, 27427, 27428, 27429
Joint Surgery 27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open) Yes Yes 27425, 27427, 27428, 27429
Joint Surgery 27429 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular Yes Yes 27425, 27427, 27428, 27429
Joint Surgery 27438 Arthroplasty, patella; with prosthesis Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447
Joint Surgery 27440 Arthroplasty, knee, tibial plateau; Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447
Joint Surgery 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447
Joint Surgery 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee; Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447
Joint Surgery 27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy Yes Yes 27438, 27440, 27441, 27442,
27443, 27445, 27446, 27447
Joint Surgery 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447
Joint Surgery 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447
Joint Surgery 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Yes Yes 27438, 27440, 27441, 27442,
27443, 27445, 27446, 27447
Joint Surgery 27486 Revision of total knee arthroplasty, with or without allograft; 1 component Yes Yes 27486, 27487, 27488
Joint Surgery 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component Yes Yes 27486, 27487, 27488
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 27488 Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee Yes Yes 27486, 27487, 27488
Joint Surgery 27580 Arthrodesis, knee, any technique Yes Yes 27580
Joint Surgery 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29820 Arthroscopy, shoulder, surgical; synovectomy, partial Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29821 Arthroscopy, shoulder, surgical; synovectomy, complete Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29822 Arthroscopy, shoulder, surgical; debridement, limited Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 29823 Arthroscopy, shoulder, surgical; debridement, extensive Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29826Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)
Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29828 Arthroscopy, shoulder, surgical; biceps tenodesis Yes Yes
29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,
29828
Joint Surgery 29860 Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) Yes Yes 29860, 29861, 29862, 29863, 29914, 29915, 29916
Joint Surgery 29861 Arthroscopy, hip, surgical; with removal of loose body or foreign body Yes Yes 29860, 29861, 29862, 29863, 29914, 29915, 29916
Joint Surgery 29862 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum Yes Yes 29860, 29861, 29862, 29863,
29914, 29915, 29916
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 29863 Arthroscopy, hip, surgical; with synovectomy Yes Yes 29860, 29861, 29862, 29863, 29914, 29915, 29916
Joint Surgery 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29873 Arthroscopy, knee, surgical; with lateral release Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 29880Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29881Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction Yes Yes
29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Joint Surgery 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) Yes Yes 29914, 29915, 29916, 29860, 29861, 29862, 29863
V1.2019 Effective: 1/1/2019
Category CPT®
Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Joint Surgery 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) Yes Yes 29914, 29915, 29916, 29860, 29861, 29862, 29863
Joint Surgery 29916 Arthroscopy, hip, surgical; with labral repair Yes Yes 29914, 29915, 29916, 29860, 29861, 29862, 29863
CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
V1.2019 Effective: 10/31/2019
CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Brachytherapy
77750 Infusion or instillation of radioelement solution (includes 3-month follow-up care) Yes Yes 77750
77761 Intracavitary radiation source application; simple Yes Yes 77761
77762 Intracavitary radiation source application; intermediate Yes Yes 77761, 77762
77763 Intracavitary radiation source application; complex Yes Yes 77761, 77762, 77763
77767 HDR radionuclide skin surface brachytherapy; lesion diameter up to 2.0 cm or 1 channel Yes Yes 77767
77768 HDR radionuclide skin surface brachytherapy; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions Yes Yes 77767, 77768
77770 HDR radionuclide interstitial or intracavitary brachytherapy; 1 channel Yes Yes 77770
77771 HDR radionuclide rate interstitial or intracavitary brachytherapy; 2 to 12 channels Yes Yes 77770, 77771
77772 HDR radionuclide interstitial or intracavitary brachytherapy; over 12 channels Yes Yes 77770, 77771, 77772
77778 Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source when performed Yes Yes 77778
0394T HDR electronic brachytherapy, skin surface application, per fraction Yes Yes
0395T HDR electronic brachytherapy, interstitial or intracavitary treatment, per fraction Yes Yes
Network Health Plan WIPrior Authorization Procedure List: Radiation Therapy
*C-CODES APPLY TO MEDICARE MEMBERSHIP ONLY
V1.2019 Effective: 10/31/2019
CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Stereotactic Radiation Therapy
77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based Yes Yes 77371
77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based Yes Yes 77372, G0339
77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions Yes Yes 77373, G0339, G0340
G0339 Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment Yes Yes G0339
G0340
Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment
Yes Yes G0340
Intensity Modulated Radiation Therapy (IMRT)
77385 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple Yes Yes 77385
77386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex Yes Yes 77385, 77386
G6015Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session
Yes Yes G6015
G6016Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session
Yes Yes G6015, G6016
V1.2019 Effective: 10/31/2019
CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Neutron Beam Radiation Therapy
77423High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)
Yes Yes 77423
Intraoperative Radiation Therapy (IORT)77424 Intraoperative radiation treatment delivery, x-ray, single treatment session Yes Yes 77424
77425 Intraoperative radiation treatment delivery, electrons, single treatment session Yes Yes 77425
Proton Beam Radiation Therapy77520 Proton treatment delivery; simple, without compensation Yes Yes 7752077522 Proton treatment delivery; simple, with compensation Yes Yes 77520, 7752277523 Proton treatment delivery; intermediate Yes Yes 77520, 77522, 77523
77525 Proton treatment delivery; complex Yes Yes 77520, 77522, 77523, 77525
Hyperthermia Treatment
77600 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) Yes Yes 77600
77605 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) Yes Yes 77600, 77605
77610 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators Yes Yes 77600, 77605, 77610
77615 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators Yes Yes 77600, 77605, 77610, 77615
77620 Hyperthermia generated by intracavitary probe(s) Yes Yes 77600, 77605, 77610, 77615, 77620
Radiation Treatment Management
G6017Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3d positional tracking, gating, 3d surface tracking), each fraction of treatment
Yes Yes
V1.2019 Effective: 10/31/2019
CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
Radiation Treatment Delivery77401 Radiation treatment delivery, superficial and/or ortho voltage, per day Yes Yes 7740177402 Radiation treatment delivery, >1 MeV; simple Yes Yes 77402
77407 Radiation treatment delivery; two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks;>=1 MeV; intermediate Yes Yes 77402, 77407
77412
Radiation treatment delivery; three or more separate treatment areas; custom blocking; tangential ports; wedges; rotational beam; field-in-field or other tissue compensation that does not meet IMRT guidelines; or electron beam; >=1 MeV; complex
Yes Yes 77402, 77407, 77412
G6003 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: up to 5mev Yes Yes G6003
G6004 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 6-10mev Yes Yes G6003, G6004
G6005 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 11-19mev Yes Yes G6003, G6004, G6005
G6006 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 20mev or greater Yes Yes G6003, G6004, G6005,
G6006
G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5mev Yes Yes G6003, G6004, G6005,
G6006, G6007
G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10mev Yes Yes G6003, G6004, G6005,
G6006, G6007, G6008
G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19mev Yes Yes
G6003, G6004, G6005,G6006, G6007, G6008,
G6009
G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater Yes Yes
G6003, G6004, G6005,G6006, G6007, G6008,
G6009, G6010
G6011Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev
Yes YesG6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011
G6012 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10mev Yes Yes
G6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011,
G6012
G6013Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19mev
Yes Yes
G6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011,
G6012, G6013
V1.2019 Effective: 10/31/2019
CPT® Code CPT® Code DescriptionCommercial
Requires Prior Authorization
MedicareRequires Prior Authorization
Allowed Billing Groupings
G6014Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20mev or greater
Yes Yes
G6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011,G6012, G6013, G6014
Radiologic Guidance77014 Computed tomography guidance for placement of radiation therapy fields Yes Yes 77014
77387 Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed Yes Yes 77387
G6001 Ultrasonic guidance for placement of radiation therapy fields Yes Yes G6001
G6002Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy Yes Yes G6001, G6002, 77014
Therapeutic Radiopharmaceuticals79101 Radiopharmaceutical, therapy, by intravenous administration Yes Yes 79101A9606 Radium RA-223 dichloride, therapeutic, per microcurie (Xofigo) Yes Yes A9606
79005 Radiopharmaceutical therapy, by oral administration; used for I-131 treatment Yes Yes 79005
79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion Yes Yes 79403
A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi Yes Yes A9513
A9543 Yttrium 90 Ibritumomab Tiuxetan (Zevalin) Yes Yes A9543
C9408 Iodine i-131 iobenguane, therapeutic, 1 millicurie No Yes C9408
CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Network Health of Wisconsin
The following codes are under management for members who have health benefits covered by Network Health of Wisconsin,administered by eviCore healthcare.
Lab Program Effective 2/1/2019
Procedure Code Full Description How Code is Managed Effective Date Termination DateLegend:
Requires Prior Authorization- Requests containing these codes should be submitted directly to eviCore
81162BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of largegene rearrangements
Requires Prior Authorization 01/01/16 None
81163 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full sequence analysis Requires Prior Authorization 01/01/19 None
81164 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) Requires Prior Authorization 01/01/19 None
81165 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequenceanalysis Requires Prior Authorization 01/01/19 None
81166 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; fullduplication/deletion anlaysis (ie, detection of large gene rearrangements) Requires Prior Authorization 01/01/19 None
81167 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; fullduplication/deletion analysis (ie, detection of large gene rearrangements) Requires Prior Authorization 01/01/19 None
81173 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation)gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None
81174 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation)gene analysis; known familial variant Requires Prior Authorization 01/01/19 None
81185 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full genesequence Requires Prior Authorization 01/01/19 None
81186 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; knownfamilial variant Requires Prior Authorization 01/01/19 None
81189 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None81190 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant (s) Requires Prior Authorization 01/01/19 None
81201 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis;full gene sequence Requires Prior Authorization 01/01/13 None
81202 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis;known familial variants Requires Prior Authorization 01/01/13 None
81203 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis;duplication/deletion variants Requires Prior Authorization 01/01/13 None
81212 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants Requires Prior Authorization 01/01/12 None
81215 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; known familial variant Requires Prior Authorization 01/01/12 None
81216 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None
81217 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; knownfamilial variant Requires Prior Authorization 01/01/12 None
81221 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familialvariants Requires Prior Authorization 01/01/12 None
Page 1 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
81222 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis;duplication/deletion variants Requires Prior Authorization 01/01/12 None
81223 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full genesequence Requires Prior Authorization 01/01/12 None
81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis,common variants (eg, *2, *3, *4, *8, *17) Requires Prior Authorization 01/01/12 None
81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, commonvariants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) Requires Prior Authorization 01/01/12 None
81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, commonvariants (eg, *2, *3, *5, *6) Requires Prior Authorization 01/01/12 None
81228Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copynumber variants (eg, bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization[CGH] microarray analysis)
Requires Prior Authorization 01/01/12 None
81229 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copynumber and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities Requires Prior Authorization 01/01/12 None
81230 CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, commonvariant(s) (eg, *2, *22) Requires Prior Authorization 01/01/18 None
81231 CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, commonvariants (eg, *2, *3, *4, *5, *6, *7) Requires Prior Authorization 01/01/18 None
81232 DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), geneanalysis, common variant(s) (eg, *2A, *4, *5, *6) Requires Prior Authorization 01/01/18 None
81238 F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence Requires Prior Authorization 01/01/18 None
81248 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familialvariant(s) Requires Prior Authorization 01/01/18 None
81249 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full genesequence Requires Prior Authorization 01/01/18 None
81252 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; fullgene sequence Requires Prior Authorization 01/01/13 None
81253 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; knownfamilial variants Requires Prior Authorization 01/01/13 None
81257HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean,alpha3.7, alpha4.2, alpha20.5, Constant Spring)
Requires Prior Authorization 01/01/12 None
81258 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; known familial variant Requires Prior Authorization 01/01/18 None
81259 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; full gene sequence Requires Prior Authorization 01/01/18 None
81269 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/18 None
81277 Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy numberand loss-of-heterozygosity variants for chromosomal abnormalities Requires Prior Authorization 01/01/20 None
81283 IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant Requires Prior Authorization 01/01/18 None81286 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None81289 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant (s) Requires Prior Authorization 01/01/19 None
81291 MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, commonvariants (eg, 677T, 1298C) Requires Prior Authorization 01/01/12 None
81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None
81293 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; known familial variants Requires Prior Authorization 01/01/12 None
81294 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None
Page 2 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
81295 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None
81296 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; known familial variants Requires Prior Authorization 01/01/12 None
81297 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None
81298 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) geneanalysis; full sequence analysis Requires Prior Authorization 01/01/12 None
81299 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) geneanalysis; known familial variants Requires Prior Authorization 01/01/12 None
81300 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) geneanalysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None
81302 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None81303 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant Requires Prior Authorization 01/01/12 None81304 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None81306 NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) Requires Prior Authorization 01/01/19 None81307 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence Requires Prior Authorization 01/01/20 None81308 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant Requires Prior Authorization 01/01/20 None
81313 PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specificantigen]) ratio (eg, prostate cancer) Requires Prior Authorization 01/01/15 None
81317 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None
81318 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; known familial variants Requires Prior Authorization 01/01/12 None
81319 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None
81321 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) geneanalysis; full sequence analysis Requires Prior Authorization 01/01/13 None
81322 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) geneanalysis; known familial variant Requires Prior Authorization 01/01/13 None
81323 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) geneanalysis; duplication/deletion variant Requires Prior Authorization 01/01/13 None
81325 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressurepalsies) gene analysis; full sequence analysis Requires Prior Authorization 01/01/13 None
81326 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressurepalsies) gene analysis; known familial variant Requires Prior Authorization 01/01/13 None
81327 SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis Requires Prior Authorization 01/01/17 None
81328 SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), geneanalysis, common variant(s) (eg, *5) Requires Prior Authorization 01/01/18 None
81335 TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) Requires Prior Authorization 01/01/18 None81336 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None
81337 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familialsequence variant(s) Requires Prior Authorization 01/01/19 None
81346 TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg,tandem repeat variant) Requires Prior Authorization 01/01/18 None
81350 UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugatedhyperbilirubinemia [Gilbert syndrome]) gene analysis, common variants (eg, *28, *36, *37) Requires Prior Authorization 01/01/12 None
81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, commonvariant(s) (eg, -1639G>A, c.173+1000C>T) Requires Prior Authorization 01/01/12 None
Page 3 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
81361 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); commonvariant(s) (eg, HbS, HbC, HbE) Requires Prior Authorization 01/01/18 None
81362 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familialvariant(s) Requires Prior Authorization 01/01/18 None
81363 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy);duplication/deletion variant(s) Requires Prior Authorization 01/01/18 None
81364 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full genesequence Requires Prior Authorization 01/01/18 None
81400 Molecular pathology procedure, Level 1 (eg, identification of single germline variant [eg, SNP] by techniquessuch as restriction enzyme digestion or melt curve analysis) Requires Prior Authorization 01/01/12 None
81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typicallyusing nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) Requires Prior Authorization 01/01/12 None
81402Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants[typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor generearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity [LOH], uniparental disomy [UPD])
Requires Prior Authorization 01/01/12 None
81403Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletionvariants of 2-5 exons)
Requires Prior Authorization 01/01/12 None
81404Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanningor duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat bySouthern blot analysis)
Requires Prior Authorization 01/01/12 None
81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutationscanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis) Requires Prior Authorization 01/01/12 None
81406 Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutationscanning or duplication/deletion variants of 26-50 exons) Requires Prior Authorization 01/01/12 None
81407 Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutationscanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) Requires Prior Authorization 01/01/12 None
81408 Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) Requires Prior Authorization 01/01/12 None
81410Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV,arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes,including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK
Requires Prior Authorization 01/01/15 None
81411Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV,arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2,MYH11, and COL3A1
Requires Prior Authorization 01/01/15 None
81412Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familialdysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysispanel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP,MCOLN1, and SMPD1
Requires Prior Authorization 01/01/16 None
81413Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergicpolymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A
Requires Prior Authorization 01/01/17 None
81414Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergicpolymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2genes, including KCNH2 and KCNQ1
Requires Prior Authorization 01/01/17 None
81415 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Requires Prior Authorization 01/01/15 None
81416 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparatorexome (eg, parents, siblings) (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/15 None
81417 Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtainedexome sequence (eg, updated knowledge or unrelated condition/syndrome) Requires Prior Authorization 01/01/15 None
81422 Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chatsyndrome), circulating cell-free fetal DNA in maternal blood Requires Prior Authorization 01/01/17 None
81425 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Requires Prior Authorization 01/01/15 None
81426 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparatorgenome (eg, parents, siblings) (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/15 None
Page 4 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
81427 Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtainedgenome sequence (eg, updated knowledge or unrelated condition/syndrome) Requires Prior Authorization 01/01/15 None
81430Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysispanel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1,MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1
Requires Prior Authorization 01/01/15 None
81431 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysispanel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes Requires Prior Authorization 01/01/15 None
81432Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, alwaysincluding BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53
Requires Prior Authorization 01/01/16 None
81433Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1,MSH2, and STK11
Requires Prior Authorization 01/01/16 None
81434Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomicsequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS,PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A
Requires Prior Authorization 01/01/16 None
81435Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis); genomic sequence analysis panel, must include sequencing of at least 10genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11
Requires Prior Authorization 01/01/15 None
81436Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis); duplication/deletion analysis panel, must include analysis of at least 5 genes,including MLH1, MSH2, EPCAM, SMAD4, and STK11
Requires Prior Authorization 01/01/15 None
81437Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignantpheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL
Requires Prior Authorization 01/01/16 None
81438Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignantpheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB,SDHC, SDHD, and VHL
Requires Prior Authorization 01/01/16 None
81439Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic rightventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at least 5cardiomyopathy-related genes (eg, DSG2, MYBPC3, MYH7, PKP2, TTN)
Requires Prior Authorization 01/01/17 None
81440Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, mustinclude analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1,PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP
Requires Prior Authorization 01/01/15 None
81442Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome,LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of atleast 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2,and SOS1
Requires Prior Authorization 01/01/16 None
81443
Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish-associated disorders [eg,Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachsdisease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, mustinclude sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR,DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)
Requires Prior Authorization 01/01/19 None
81445Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis whenperformed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA,PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants orrearrangements, if performed
Requires Prior Authorization 01/01/15 None
81448Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysispanel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2,MPZ, REEP1, SPAST, SPG11, SPTLC1)
Requires Prior Authorization 01/01/18 None
81450Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNAanalysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS,KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants orrearrangements, or isoform expression or mRNA expression levels, if performed
Requires Prior Authorization 01/01/15 None
81455
Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNAanalysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2,EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR,PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, ifperformed
Requires Prior Authorization 01/01/15 None
Page 5 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
81460Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, andstroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, andretinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must includesequence analysis of entire mitochondrial genome with heteroplasmy detection
Requires Prior Authorization 01/01/15 None
81465 Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressiveexternal ophthalmoplegia), including heteroplasmy detection, if performed Requires Prior Authorization 01/01/15 None
81470X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysispanel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2
Requires Prior Authorization 01/01/15 None
81471X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion geneanalysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2
Requires Prior Authorization 01/01/15 None
81479 Unlisted molecular pathology procedure Requires Prior Authorization 01/01/13 None
81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognosticalgorithm reported as a disease activity score Requires Prior Authorization 01/01/16 None
81493 Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing wholeperipheral blood, algorithm reported as a risk score Requires Prior Authorization 01/01/16 None
81500 Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausalstatus, algorithm reported as a risk score Requires Prior Authorization 01/01/13 None
81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin,transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score Requires Prior Authorization 01/01/14 None
81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores Requires Prior Authorization 01/01/14 None
81518Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithms reported as percentage risk formetastatic recurrence and likelihood of benefit from extended endocrine therapy
Requires Prior Authorization 01/01/19 None
81519 Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixedparaffin-embedded tissue, algorithm reported as recurrence score Requires Prior Authorization 01/01/15 None
81520 Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score Requires Prior Authorization 01/01/18 None
81521Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeepinggenes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related torisk of distant metastasis
Requires Prior Authorization 01/01/18 None
81522 Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping),utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score Requires Prior Authorization 01/01/20 None
81525 Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score Requires Prior Authorization 01/01/16 None
81528Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRASmutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reportedas a positive or negative result
Requires Prior Authorization 01/01/16 None
81535 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology,predictive algorithm reported as a drug response score; first single drug or drug combination Requires Prior Authorization 01/01/16 None
81536Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology,predictive algorithm reported as a drug response score; each additional single drug or drug combination (Listseparately in addition to code for primary procedure)
Requires Prior Authorization 01/01/16 None
81538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic andpredictive algorithm reported as good versus poor overall survival Requires Prior Authorization 01/01/16 None
81539 Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA,and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score Requires Prior Authorization 01/01/17 None
81540Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype
Requires Prior Authorization 01/01/16 None
81541Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specificmortality risk score
Requires Prior Authorization 01/01/18 None
Page 6 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
81542 Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixedparaffin-embedded tissue, algorithm reported as metastasis risk score Requires Prior Authorization 01/01/20 None
81545 Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as acategorical result (eg, benign or suspicious) Requires Prior Authorization 01/01/16 None
81551Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1),utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detectionon repeat biopsy
Requires Prior Authorization 01/01/18 None
81552Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported asrisk of metastasis
Requires Prior Authorization 01/01/20 None
81595 Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score Requires Prior Authorization 01/01/16 None
81596Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin,apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scoresfor fibrosis and necroinflammatory activity in liver
Requires Prior Authorization 01/01/19 None
81599 Unlisted multianalyte assay with algorithmic analysis Requires Prior Authorization 01/01/13 None84999 Unlisted chemistry procedure Requires Prior Authorization 01/01/93 None
0001U Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 bloodgroups, utilizing whole blood, common RBC alleles reported Requires Prior Authorization 02/01/17 None
0002MLiver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT,haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported asquantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH)
Requires Prior Authorization 01/01/13 None
0003MLiver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT,haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported asquantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH)
Requires Prior Authorization 01/01/13 None
0004M Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithmreported as a risk score Requires Prior Authorization 01/01/13 None
0005U Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine,algorithm reported as risk score Requires Prior Authorization 05/01/17 None
0006M Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue,with alpha-fetoprotein level, algorithm reported as a risk classifier Requires Prior Authorization 01/01/15 None
0007M Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizingwhole peripheral blood, algorithm reported as a nomogram of tumor disease index Requires Prior Authorization 01/01/15 None
0011M Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR testutilizing blood plasma and urine, algorithms to predict high-grade prostate cancer risk Requires Prior Authorization 01/01/18 None
0012MOncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK,HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for havingurothelial carcinoma
Requires Prior Authorization 04/01/18 None
0012U Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, wholeblood, report of specific gene rearrangement(s) Requires Prior Authorization 08/01/17 None
0013MOncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK,HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for havingrecurrent urothelial carcinoma
Requires Prior Authorization 04/01/18 None
0013U Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing,DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s) Requires Prior Authorization 08/01/17 None
0014U Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome nextgenerationsequencing, DNA, whole blood or bone marrow, report of specific gene rearrangement(s) Requires Prior Authorization 08/01/17 None
0018U Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate,algorithm reported as a positive or negative result for moderate to high risk of malignancy Requires Prior Authorization 10/01/17 None
0019U Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue orfresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents Requires Prior Authorization 10/01/17 None
0022UTargeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes,interrogation for sequence variants and rearrangements, reported as presence/absence of variants andassociated therapy(ies) to consider
Requires Prior Authorization 10/01/17 None
Page 7 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
0026UOncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroidnodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or"Negative, low probability of malignancy")
Requires Prior Authorization 01/01/18 None
0029U Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2,CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) Requires Prior Authorization 01/01/18 None
0030U Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1,rs12777823) Requires Prior Authorization 01/01/18 None
0031U CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, commonvariants (ie, *1F, *1K, *6, *7) Requires Prior Authorization 01/01/18 None
0032U COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant Requires Prior Authorization 01/01/18 None
0033UHTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (eg, citaloprammetabolism) gene analysis, common variants (ie, HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-759C>T] and rs1414334 [c.551-3008C>G])
Requires Prior Authorization 01/01/18 None
0034U TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), geneanalysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15*3, *4, *5) Requires Prior Authorization 01/01/18 None
0036U Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen,sequence analyses Requires Prior Authorization 04/01/18 None
0037UTargeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation forsequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumormutational burden
Requires Prior Authorization 04/01/18 None
0045UOncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by realtime RT-PCR of 12 genes (7content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrencescore
Requires Prior Authorization 07/01/18 None
0047U Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score Requires Prior Authorization 07/01/18 None
0048UOncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associatedgenes, including interrogation for somatic mutations and microsatellite instability, matched with normalspecimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s)
Requires Prior Authorization 07/01/18 None
0050U Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes,interrogation for sequence variants, copy number variants or rearrangements Requires Prior Authorization 07/01/18 None
0053U Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsyspecimen, algorithm reported as probability of higher tumor grade Requires Prior Authorization 07/01/18 None
0055U Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotidepolymorphism targets and two control targets), plasma Requires Prior Authorization 07/01/18 None
0056U Hematology (acute myelogenous leukemia), DNA, whole genome nextgeneration sequencing to detect generearrangement(s), blood or bone marrow, report of specific gene rearrangement(s) Requires Prior Authorization 07/01/18 None
0060U Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA inmaternal blood Requires Prior Authorization 07/01/18 None
0067UOncology (breast), immunohistochemistry, protein expression profiling of 4 biomarkers (matrix metalloproteinase-1 [MMP-1], carcinoembryonic antigen-related cell adhesion molecule 6 [CEACAM6], hyaluronoglucosaminidase[HYAL1], highly expressed in cancer protein [HEC1]), formalin-fixed paraffin-embedded precancerous breasttissue, algorithm reported as carcinoma risk score
Requires Prior Authorization 10/01/18 None
0069U Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin fixed paraffin-embeddedtissue, algorithm reported as an expression score Requires Prior Authorization 10/01/18 None
0070UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, commonand select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35,*36, *41, *57, *61, *63, *68, *83, *xN)
Requires Prior Authorization 10/01/18 None
0071U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full genesequence (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/18 None
0072U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/18 None
0073U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/18 None
Page 8 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
0074UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (List separately in addition tocode for primary procedure)
Requires Prior Authorization 10/01/18 None
0075UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, 5’ gene duplication/multiplication) (List separately in addition to code for primaryprocedure)
Requires Prior Authorization 10/01/18 None
0076UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, 3’ gene duplication/ multiplication) (List separately in addition to code for primaryprocedure)
Requires Prior Authorization 10/01/18 None
0078UPain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH,DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab orother germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder
Requires Prior Authorization 10/01/18 None
0079U Comparative DNA analysis using multiple selected single-nucleotide polymorphisms (SNPs), urine and buccalDNA, for specimen identity verification Requires Prior Authorization 10/01/18 None
0081UOncology (uveal melanoma), mRNA, gene-expression profiling by real-time RT-PCR of 15 genes (12 content and3 housekeeping genes), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithmreported as risk of metastasis
Requires Prior Authorization 01/01/19 None
0084U Red blood cell antigen typing, DNA, genotyping of 10 blood groups with phenotype prediction of 37 red blood cellantigens Requires Prior Authorization 07/01/19 None
0087U Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsytissue, allograft rejection and injury algorithm reported as a probability score Requires Prior Authorization 07/01/19 None
0088U Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizingtransplant biopsy tissue, algorithm reported as a probability score for rejection Requires Prior Authorization 07/01/19 None
0089U Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collectionusing adhesive patch(es) Requires Prior Authorization 07/01/19 None
0090UOncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a categorical result (ie,benign, indeterminate, malignant)
Requires Prior Authorization 07/01/19 None
0094U Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis Requires Prior Authorization 07/01/19 None
0101UHereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis), genomic sequence analysis panel utilizing a combination of NGS, Sanger,MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (15genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only])
Requires Prior Authorization 07/01/19 None
0102UHereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arrayCGH, with mRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencingand deletion/duplication])
Requires Prior Authorization 07/01/19 None
0103UHereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequenceanalysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolvevariants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM[deletion/duplication only])
Requires Prior Authorization 07/01/19 None
0104UHereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditarycolorectal cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arrayCGH, with MRNA analytics to resolve variants of unknown significance when indicated (32 genes sequencingand deletion/duplication], EPCAM and GREM1 [deletion/duplication only])
Requires Prior Authorization 07/01/19 10/01/19
0111U Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) geneanalysis utilizing formalin-fixed paraffin-embedded tissue Requires Prior Authorization 10/01/19 None
0113U Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostaticmassage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score Requires Prior Authorization 10/01/19 None
0114U Gastroenterology (Barrett’s esophagus), VIM and CCNA1 methylation analysis, esophageal cells, algorithmreported as likelihood for Barrett’s esophagus Requires Prior Authorization 10/01/19 None
0118U Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generationsequencing, plasma, reported as percentage of donor-derived cell-free DNA in the total cell-free DNA Requires Prior Authorization 10/01/19 None
0120UOncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin-embedded tissue, algorithm reportedas likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) withcell of origin subtyping in the latter
Requires Prior Authorization 10/01/19 None
Page 9 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination Date
0129UHereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2,CDH1, CHEK2, PALB2, PTEN, and TP53)
Requires Prior Authorization 10/01/19 None
0130UHereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2,MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure)
Requires Prior Authorization 10/01/19 None
0131UHereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code forprimary procedure)
Requires Prior Authorization 10/01/19 None
0132UHereditary ovarian cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code forprimary procedure)
Requires Prior Authorization 10/01/19 None
0133U Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (Listseparately in addition to code for primary procedure) Requires Prior Authorization 10/01/19 None
0134UHereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditarycolorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code forprimary procedure)
Requires Prior Authorization 10/01/19 None
0135UHereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer,hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition tocode for primary procedure)
Requires Prior Authorization 10/01/19 None
0136U ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately inaddition to code for primary procedure) Requires Prior Authorization 10/01/19 None
0137U PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) mRNA sequence analysis (Listseparately in addition to code for primary procedure) Requires Prior Authorization 10/01/19 None
0138U BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/19 None
0153UOncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizingformalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s)with information on immune cell involvement
Requires Prior Authorization 01/01/20 None
0156U Copy number (eg, intellectual disability, dysmorphology), sequence analysis Requires Prior Authorization 01/01/20 None
0157U APC (APC regulator of WNT signaling pathway) (eg, familial adenomatosis polyposis [FAP]) mRNA sequenceanalysis (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None
0158U MLH1 (mutL homolog 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA sequenceanalysis (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None
0159U MSH2 (mutS homolog 2) (eg, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (Listseparately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None
0160U MSH6 (mutS homolog 6) (eg, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (Listseparately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None
0161U PMS2 (PMS1 homolog 2, mismatch repair system component) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) mRNA sequence analysis (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None
0162U Hereditary colon cancer (Lynch syndrome), targeted mRNA sequence analysis panel (MLH1, MSH2, MSH6,PMS2) (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None
G9143 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) Requires Prior Authorization 08/03/09 NoneS3800 Genetic testing for amyotrophic lateral sclerosis (als) Requires Prior Authorization 07/01/07 None
S3840 Dna analysis for germline mutations of the ret proto-oncogene for susceptibility to multiple endocrine neoplasiatype 2 Requires Prior Authorization 07/01/03 None
S3841 Genetic testing for retinoblastoma Requires Prior Authorization 07/01/03 NoneS3842 Genetic testing for von hippel-lindau disease Requires Prior Authorization 07/01/03 NoneS3844 Dna analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness Requires Prior Authorization 07/01/03 NoneS3845 Genetic testing for alpha-thalassemia Requires Prior Authorization 07/01/03 NoneS3846 Genetic testing for hemoglobin e beta-thalassemia Requires Prior Authorization 07/01/03 NoneS3850 Genetic testing for sickle cell anemia Requires Prior Authorization 07/01/03 None
Page 10 of 11
Procedure Code Full Description How Code is Managed Effective Date Termination DateS3852 Dna analysis for apoe epsilon 4 allele for susceptibility to alzheimer's disease Requires Prior Authorization 07/01/03 NoneS3854 Gene expression profiling panel for use in the management of breast cancer treatment Requires Prior Authorization 01/01/06 None
S3861 Genetic testing, sodium channel, voltage-gated, type v, alpha subunit (scn5a) and variants for suspectedbrugada syndrome Requires Prior Authorization 10/01/08 None
S3865 Comprehensive gene sequence analysis for hypertrophic cardiomyopathy Requires Prior Authorization 04/01/09 None
S3866 Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (hcm) in an individual with aknown hcm mutation in the family Requires Prior Authorization 04/01/09 None
S3870 Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorderand/or intellectual disability Requires Prior Authorization 04/01/09 None
Footer 1 CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of theAmerican Medical Association.
Footer 2 All procedure codes (81105-81599) included in a multiple procedure code panel are subject to medical necessityreview if any code requires prior authorization.
Page 11 of 11
Network Health (NWH-WI Medicare)
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WIMedicare) Administration Technique Drug Class
5-Fluorouracil 5FU, Adrucil J9190 Y INJECTABLE Primary
Ado-Trastuzumab Emtansine Kadcyla J9354 Y INJECTABLE Primary
Aldesleukin Proleukin, Interleukin-2 J9015 Y INJECTABLE Primary
Arsenic Trioxide Trisenox J9017 Y INJECTABLE Primary
Asparaginase Erwinaze J9019 Y INJECTABLE Primary
Atezolizumab Tecentriq J9022 Y INJECTABLE Primary
Avelumab Bavencio J9023 Y INJECTABLE Primary
Azacitidine Vidaza J9025 Y INJECTABLE Primary
BCG TheraCys, Tice J9031 Y INJECTABLE Primary
Belinostat Beleodaq J9032 Y INJECTABLE Primary
Bendamustine Bendamustine (Not otherwise specified) C9399 Y INJECTABLE Primary
Bendamustine Bendamustine (Not otherwise specified) J9999 Y INJECTABLE Primary
Bendamustine Treanda J9033 Y INJECTABLE Primary
Bendamustine HCL Belrapzo C9042 Y INJECTABLE Primary
Bendamustine HCL Bendeka J9034 Y INJECTABLE Primary
Bevacizumab Avastin J9035 Y INJECTABLE Primary
Bevacizumab-awwb (not currentlyavailable on the market)
Mvasi Q5107 Y INJECTABLE Primary
Bleomycin Blenoxane J9040 Y INJECTABLE Primary
Blinatumomab Blincyto J9039 Y INJECTABLE Primary
Bortezomib Velcade J9041 Y INJECTABLE Primary
Bortezomib Bortezomib (not otherwise specified) J9044 Y INJECTABLE Primary
Brentuximab Vedotin Adcetris J9042 Y INJECTABLE Primary
Cabazitaxel Jevtana J9043 Y INJECTABLE Primary
Calaspargase pegol-mknl Asparlas J3490 Y INJECTABLE Primary
Calaspargase pegol-mknl Asparlas J3590 Y INJECTABLE Primary
Carboplatin Paraplatin J9045 Y INJECTABLE Primary
Carfilzomib Kyprolis J9047 Y INJECTABLE Primary
Carmustine BiCNU, BCNU J9050 Y INJECTABLE Primary
Cemiplimab-rwlc Libtayo C9399 Y INJECTABLE Primary
Cemiplimab-rwlc Libtayo J9999 Y INJECTABLE Primary
Cemiplimab-rwlc Libtayo C9044 Y INJECTABLE Primary
Cetuximab Erbitux J9055 Y INJECTABLE Primary
Cisplatin Platinol J9060 Y INJECTABLE Primary
Cladribine Leustatin J9065 Y INJECTABLE Primary
Page 1 of 6
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WIMedicare) Administration Technique Drug Class
Clofarabine Clolar J9027 Y INJECTABLE Primary
Copanlisib Aliqopa J9057 Y INJECTABLE Primary
Cyclophosphamide - inj Cytoxan, Endoxan-Asta J9070 Y INJECTABLE Primary
Cytarabine Ara-C J9100 Y INJECTABLE Primary
Cytarabine-Liposome DepoCyt J9098 Y INJECTABLE Primary
Dacarbazine DTIC-Dome J9130 Y INJECTABLE Primary
Dactinomycin Cosmegen, Actinomycin J9120 Y INJECTABLE Primary
Daratumumab Darzalex J9145 Y INJECTABLE Primary
Daunorubicin Cerubidine J9150 Y INJECTABLE Primary
Decitabine Dacogen J0894 Y INJECTABLE Primary
Degarelix Firmagon J9155 Y INJECTABLE Primary
Dinutuximab Unituxin C9399 Y INJECTABLE Primary
Dinutuximab Unituxin J9999 Y INJECTABLE Primary
Docetaxel Taxotere J9171 Y INJECTABLE Primary
Doxorubicin HCL Adriamycin J9000 Y INJECTABLE Primary
Doxorubicin HCL (liposomal) Lipodox Q2049 Y INJECTABLE Primary
Doxorubicin HCL (liposomal) Doxil Q2050 Y INJECTABLE Primary
Durvalumab Imfinzi J9173 Y INJECTABLE Primary
Elotuzumab Empliciti J9176 Y INJECTABLE Primary
Epirubicin Ellence J9178 Y INJECTABLE Primary
Eribulin mesylate Halaven J9179 Y INJECTABLE Primary
Etoposide - inj Toposar, VePesid, Etopophos J9181 Y INJECTABLE Primary
Floxuridine FUDR J9200 Y INJECTABLE Primary
Fludarabine Phosphate Fludara, Oforta J9185 Y INJECTABLE Primary
Fulvestrant Faslodex J9395 Y INJECTABLE Primary
Gemcitabine Gemzar J9201 Y INJECTABLE Primary
Gemcitabine HCL - NACL Infugem J3490 Y INJECTABLE Primary
Gemcitabine HCL - NACL Infugem J9999 Y INJECTABLE Primary
Gemtuzumab Ozogamicin Mylotarg J9203 Y INJECTABLE Primary
Goserelin acetate implant Zoladex J9202 Y INJECTABLE Primary
Histrelin Implant Vantas J9225 Y INJECTABLE Primary
Idarubicin HCL - inj Idamycin J9211 Y INJECTABLE Primary
Ifosfamide Ifex, Mitoxana J9208 Y INJECTABLE Primary
Inotuzumab Ozogamicin Besponsa J9229 Y INJECTABLE Primary
Interferon, alfa-2b, recombinant Intron A J9214 Y INJECTABLE Primary
Interferon, gamma-1b Actimmune J9216 Y INJECTABLE Primary
Ipilumumab Yervoy J9228 Y INJECTABLE Primary
Page 2 of 6
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WIMedicare) Administration Technique Drug Class
Irinotecan Camptosar J9206 Y INJECTABLE Primary
Irinotecan Liposome Onivyde J9205 Y INJECTABLE Primary
Ixabepilone Ixempra J9207 Y INJECTABLE Primary
Lanreotide Somatuline Depot J1930 Y INJECTABLE Primary
Leucovorin - inj Leucovorin J0640 Y INJECTABLE Primary
Leuprolide Acetate Eligard, Lupron Depot, Lupron,Leuprolide Acetate
J1950 Y INJECTABLE Primary
Leuprolide Acetate Eligard, Lupron Depot, Lupron,Leuprolide Acetate
J9217 Y INJECTABLE Primary
Leuprolide Acetate Eligard, Lupron Depot, Lupron,Leuprolide Acetate
J9218 Y INJECTABLE Primary
Levoleucovorin Fusilev J0641 Y INJECTABLE Primary
Levoleucovorin Khapzory J3490 Y INJECTABLE Primary
Levoleucovorin Khapzory C9399 Y INJECTABLE Primary
Levoleucovorin Khapzory C9043 Y INJECTABLE Primary
Liposome-encapsulatedcombination of Daunorubicin andCytarabine
Vyxeos J9153 Y INJECTABLE Primary
Mechlorethamine HCL Mustragen J9230 Y INJECTABLE Primary
Melphalan HCL - inj Alkeran J9245 Y INJECTABLE Primary
Methotrexate Sodium (J9250: 5mg) Folex, Methotrexate J9250 Y INJECTABLE Primary
Methotrexate Sodium (J9260:50mg)
Folex, Methotrexate J9260 Y INJECTABLE Primary
Mitomycin Mutamycin J9280 Y INJECTABLE Primary
Mitoxantrone HCL Novantrone J9293 Y INJECTABLE Primary
Moxetumomab pasudotox-tdfk Lumoxiti J9999 Y INJECTABLE Primary
Moxetumomab pasudotox-tdfk Lumoxiti C9045 Y INJECTABLE Primary
Mogamulizumab-kpkc Poteligeo J9999 Y INJECTABLE Primary
Mogamulizumab-kpkc Poteligeo C9038 Y INJECTABLE Primary
Necitumumab Portrazza J9295 Y INJECTABLE Primary
Nelarabine Arranon J9261 Y INJECTABLE Primary
Nivolumab Opdivo J9299 Y INJECTABLE Primary
Obinutuzumab Gazyva J9301 Y INJECTABLE Primary
Octreotide depot Sandostatin J2353 Y INJECTABLE Primary
Octreotide non-depot Sandostatin J2354 Y INJECTABLE Primary
Ofatumumab Arzerra J9302 Y INJECTABLE Primary
Olaratumab Lartruvo J9285 Y INJECTABLE Primary
Omacetaxine Synribo J9262 Y INJECTABLE Primary
Oxaliplatin Eloxatin J9263 Y INJECTABLE Primary
Paclitaxel Nov-Onxol, Taxol J9267 Y INJECTABLE Primary
Paclitaxel (albumin-bound) Abraxane J9264 Y INJECTABLE Primary
Page 3 of 6
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WIMedicare) Administration Technique Drug Class
Panitumumab Vectibix J9303 Y INJECTABLE Primary
Pegaspargase Oncaspar J9266 Y INJECTABLE Primary
Peginterferon, alfa-2a Pegasys J3590 Y INJECTABLE Primary
Peginterferon, alfa-2a Pegasys S0145 Y INJECTABLE Primary
Peginterferon, alfa-2b PegIntron J3590 Y INJECTABLE Primary
Peginterferon, alfa-2b PegIntron S0148 Y INJECTABLE Primary
Peginterferon, alfa-2b Sylatron C9399 Y INJECTABLE Primary
Peginterferon, alfa-2b Sylatron J9999 Y INJECTABLE Primary
Pembrolizumab Keytruda J9271 Y INJECTABLE Primary
Pemetrexed Alimta J9305 Y INJECTABLE Primary
Pentostatin Nipent J9268 Y INJECTABLE Primary
Pertuzumab Perjeta J9306 Y INJECTABLE Primary
Porfimer Sodium Photofrin J9600 Y INJECTABLE Primary
Pralatrexate Folotyn J9307 Y INJECTABLE Primary
Ramucirumab Cyramza J9308 Y INJECTABLE Primary
Rituximab Rituxan J9312 Y INJECTABLE Primary
Rituximab-abbs Truxima C9399 Y INJECTABLE Primary
Rituximab-abbs Truxima J3490 Y INJECTABLE Primary
Rituximab-abbs Truxima J3590 Y INJECTABLE Primary
Rituximab-abbs Truxima J9999 Y INJECTABLE Primary
Rituximab and HyaluronidaseHuman
Rituxan Hycela J9311 Y INJECTABLE Primary
Romidepsin Istodax J9315 Y INJECTABLE Primary
Siltuximab Sylvant J2860 Y INJECTABLE Primary
Sipuleucel-T Provenge Q2043 Y INJECTABLE Primary
Streptozocin Zanosar J9320 Y INJECTABLE Primary
Tagraxofusp-erzs (not available tomarket yet)
Elzonris C9399 Y INJECTABLE Primary
Tagraxofusp-erzs (not available tomarket yet)
Elzonris J9999 Y INJECTABLE Primary
Talimogene Laherparepvec Imlygic J9325 Y INJECTABLE Primary
Temozolomide - inj Temodar J9328 Y INJECTABLE Primary
Temsirolimus Torisel J9330 Y INJECTABLE Primary
Teniposide Vumon Q2017 Y INJECTABLE Primary
Thiotepa Thioplex J9340 Y INJECTABLE Primary
Tocilizumab Actemra J3262 Y INJECTABLE Primary
Topotecan - inj Hycamtin J9351 Y INJECTABLE Primary
Trabectedin Yondelis J9352 Y INJECTABLE Primary
Trastuzumab Herceptin J9355 Y INJECTABLE Primary
Page 4 of 6
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WIMedicare) Administration Technique Drug Class
Trastuzumab-dkst (Not currently onthe Market)
Ogiviri J3490 Y INJECTABLE Primary
Trastuzumab-dkst (Not currently onthe Market)
Ogiviri J3590 Y INJECTABLE Primary
Trastuzumab-dkst (Not currently onthe Market)
Ogiviri J9999 Y INJECTABLE Primary
Trastuzumab-dttb (Not currently onthe Market)
Ontruzant J3490 Y INJECTABLE Primary
Trastuzumab-dttb (Not currently onthe Market)
Ontruzant J3590 Y INJECTABLE Primary
Trastuzumab-pkrb Herzuma J3490 Y INJECTABLE Primary
Trastuzumab-pkrb Herzuma J3590 Y INJECTABLE Primary
Trastuzumab-qyyp Trazimera J3490 Y INJECTABLE Primary
Trastuzumab-qyyp Trazimera J3590 Y INJECTABLE Primary
Trastuzumab and hyaluronidase-oysk
Herceptin Hylecta J3490 Y INJECTABLE Primary
Trastuzumab and hyaluronidase-oysk
Herceptin Hylecta J3590 Y INJECTABLE Primary
Triptorelin Pamoate Trelstar J3315 Y INJECTABLE Primary
Valrubicin Valstar J9357 Y INJECTABLE Primary
Vinblastine Sulfate Velban J9360 Y INJECTABLE Primary
Vincristine Sulfate Oncovin, Vincasar PFS J9370 Y INJECTABLE Primary
Vincristine Sulfate Liposome Marqibo J9371 Y INJECTABLE Primary
Vinorelbine Tartrate Navelbine J9390 Y INJECTABLE Primary
Zivafibercept Zaltrap J9400 Y INJECTABLE Primary
Capecitabine - oral Xeloda (150 mg) J8520 Y - Medicare Part B only ORAL Primary
Etoposide - oral Toposar J8560 Y - Medicare Part B only ORAL Primary
Temozolomide - oral Temodar J8700 Y - Medicare Part B only ORAL Primary
Topotecan - oral Hycamtin J8705 Y - Medicare Part B only ORAL Primary
Aprepitant Cinvanti J0185 Y INJECTABLE Supportive/Antiemetic
Darbepoetin alfa Aranesp J0881 Y INJECTABLE Supportive
Denosumab Xgeva, Prolia J0897 Y INJECTABLE Supportive
Epoetin alfa Epogen, Procrit J0885 Y INJECTABLE Supportive
Epoetin alfa-epbx Retacrit Q5106 Y INJECTABLE Supportive
Filgrastim Neupogen J1442 Y INJECTABLE Supportive
Filgrastim-aafi Nivestym Q5110 Y INJECTABLE Supportive
Filgrastim-sndz Zarxio Q5101 Y INJECTABLE Supportive
Fosaprepitant Emend J1453 Y INJECTABLE Supportive/Antiemetic
Granisetron Sustol J1627 Y INJECTABLE Supportive/Antiemetic
Ibandronate sodium (manage onlyfor NWH WI Medicare)
Boniva J1740 Y INJECTABLE Supportive
Lanreotide Somatuline Depot J1930 Y INJECTABLE Supportive
Page 5 of 6
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WIMedicare) Administration Technique Drug Class
Fosnetupitant/Palonosetron Akynzeo J1454 Y INJECTABLE Supportive/Antiemetic
Palonosetron Aloxi J2469 Y INJECTABLE Supportive/Antiemetic
Pamidronate Disodium Aredia J2430 Y INJECTABLE Supportive
Pegfilgrastim Neulasta J2505 Y INJECTABLE Supportive
Pegfilgrastim-cbqv Udenyca Q5111 Y INJECTABLE Supportive
Pegfilgrastim-jmdb Fulphila Q5108 Y INJECTABLE Supportive
Sargramostim Leukine J2820 Y INJECTABLE Supportive
Tbo-filgrastim Granix J1447 Y INJECTABLE Supportive
Zoledronic Acid Zometa J3489 Y INJECTABLE Supportive
Page 6 of 6
Network Health (NWH-WI Commercial)
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
5-Fluorouracil 5FU, Adrucil J9190 Y INJECTABLE Primary
Ado-Trastuzumab Emtansine Kadcyla J9354 Y INJECTABLE Primary
Aldesleukin Proleukin, Interleukin-2 J9015 Y INJECTABLE Primary
Arsenic Trioxide Trisenox J9017 Y INJECTABLE Primary
Asparaginase Erwinaze J9019 Y INJECTABLE Primary
Atezolizumab Tecentriq J9022 Y INJECTABLE Primary
Avelumab Bavencio J9023 Y INJECTABLE Primary
Azacitidine Vidaza J9025 Y INJECTABLE Primary
BCG TheraCys, Tice J9031 Y INJECTABLE Primary
Belinostat Beleodaq J9032 Y INJECTABLE Primary
Bendamustine Bendamustine (Not otherwise specified) C9399 Y INJECTABLE Primary
Bendamustine Bendamustine (Not otherwise specified) J9999 Y INJECTABLE Primary
Bendamustine Treanda J9033 Y INJECTABLE Primary
Bendamustine HCL Belrapzo C9042 Y INJECTABLE Primary
Bendamustine HCL Bendeka J9034 Y INJECTABLE Primary
Bevacizumab Avastin J9035 Y INJECTABLE Primary
Bevacizumab-awwb (not currentlyavailable on the market)
Mvasi Q5107 Y INJECTABLE Primary
Bleomycin Blenoxane J9040 Y INJECTABLE Primary
Blinatumomab Blincyto J9039 Y INJECTABLE Primary
Bortezomib Velcade J9041 Y INJECTABLE Primary
Bortezomib Bortezomib (not otherwise specified) J9044 Y INJECTABLE Primary
Brentuximab Vedotin Adcetris J9042 Y INJECTABLE Primary
Cabazitaxel Jevtana J9043 Y INJECTABLE Primary
Calaspargase pegol-mknl Asparlas J3490 Y INJECTABLE Primary
Calaspargase pegol-mknl Asparlas J3590 Y INJECTABLE Primary
Carboplatin Paraplatin J9045 Y INJECTABLE Primary
Carfilzomib Kyprolis J9047 Y INJECTABLE Primary
Carmustine BiCNU, BCNU J9050 Y INJECTABLE Primary
Cemiplimab-rwlc Libtayo C9399 Y INJECTABLE Primary
Cemiplimab-rwlc Libtayo J9999 Y INJECTABLE Primary
Cemiplimab-rwlc Libtayo C9044 Y INJECTABLE Primary
Cetuximab Erbitux J9055 Y INJECTABLE Primary
Cisplatin Platinol J9060 Y INJECTABLE Primary
Cladribine Leustatin J9065 Y INJECTABLE Primary
Page 1 of 8
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
Clofarabine Clolar J9027 Y INJECTABLE Primary
Copanlisib Aliqopa J9057 Y INJECTABLE Primary
Cyclophosphamide - inj Cytoxan, Endoxan-Asta J9070 Y INJECTABLE Primary
Cytarabine Ara-C J9100 Y INJECTABLE Primary
Cytarabine-Liposome DepoCyt J9098 Y INJECTABLE Primary
Dacarbazine DTIC-Dome J9130 Y INJECTABLE Primary
Dactinomycin Cosmegen, Actinomycin J9120 Y INJECTABLE Primary
Daratumumab Darzalex J9145 Y INJECTABLE Primary
Daunorubicin Cerubidine J9150 Y INJECTABLE Primary
Decitabine Dacogen J0894 Y INJECTABLE Primary
Degarelix Firmagon J9155 Y INJECTABLE Primary
Dinutuximab Unituxin C9399 Y INJECTABLE Primary
Dinutuximab Unituxin J9999 Y INJECTABLE Primary
Docetaxel Taxotere J9171 Y INJECTABLE Primary
Doxorubicin HCL Adriamycin J9000 Y INJECTABLE Primary
Doxorubicin HCL (liposomal) Lipodox Q2049 Y INJECTABLE Primary
Doxorubicin HCL (liposomal) Doxil Q2050 Y INJECTABLE Primary
Durvalumab Imfinzi J9173 Y INJECTABLE Primary
Elotuzumab Empliciti J9176 Y INJECTABLE Primary
Epirubicin Ellence J9178 Y INJECTABLE Primary
Eribulin mesylate Halaven J9179 Y INJECTABLE Primary
Etoposide - inj Toposar, VePesid, Etopophos J9181 Y INJECTABLE Primary
Floxuridine FUDR J9200 Y INJECTABLE Primary
Fludarabine Phosphate Fludara, Oforta J9185 Y INJECTABLE Primary
Fulvestrant Faslodex J9395 Y INJECTABLE Primary
Gemcitabine Gemzar J9201 Y INJECTABLE Primary
Gemcitabine HCL - NACL Infugem J3490 Y INJECTABLE Primary
Gemcitabine HCL - NACL Infugem J9999 Y INJECTABLE Primary
Gemtuzumab Ozogamicin Mylotarg J9203 Y INJECTABLE Primary
Goserelin acetate implant Zoladex J9202 Y INJECTABLE Primary
Histrelin Implant Vantas J9225 Y INJECTABLE Primary
Idarubicin HCL - inj Idamycin J9211 Y INJECTABLE Primary
Ifosfamide Ifex, Mitoxana J9208 Y INJECTABLE Primary
Inotuzumab Ozogamicin Besponsa J9229 Y INJECTABLE Primary
Interferon, alfa-2b, recombinant Intron A J9214 Y INJECTABLE Primary
Interferon, gamma-1b Actimmune J9216 Y INJECTABLE Primary
Ipilumumab Yervoy J9228 Y INJECTABLE Primary
Page 2 of 8
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
Irinotecan Camptosar J9206 Y INJECTABLE Primary
Irinotecan Liposome Onivyde J9205 Y INJECTABLE Primary
Ixabepilone Ixempra J9207 Y INJECTABLE Primary
Lanreotide Somatuline Depot J1930 Y INJECTABLE Primary
Leucovorin - inj Leucovorin J0640 Y INJECTABLE Primary
Leuprolide Acetate Eligard, Lupron Depot, Lupron,Leuprolide Acetate
J1950 Y INJECTABLE Primary
Leuprolide Acetate Eligard, Lupron Depot, Lupron,Leuprolide Acetate
J9217 Y INJECTABLE Primary
Leuprolide Acetate Eligard, Lupron Depot, Lupron,Leuprolide Acetate
J9218 Y INJECTABLE Primary
Levoleucovorin Fusilev J0641 Y INJECTABLE Primary
Levoleucovorin Khapzory J3490 Y INJECTABLE Primary
Levoleucovorin Khapzory C9399 Y INJECTABLE Primary
Levoleucovorin Khapzory C9043 Y INJECTABLE Primary
Liposome-encapsulatedcombination of Daunorubicin andCytarabine
Vyxeos J9153 Y INJECTABLE Primary
Mechlorethamine HCL Mustragen J9230 Y INJECTABLE Primary
Melphalan HCL - inj Alkeran J9245 Y INJECTABLE Primary
Methotrexate Sodium (J9250: 5mg) Folex, Methotrexate J9250 Y INJECTABLE Primary
Methotrexate Sodium (J9260:50mg)
Folex, Methotrexate J9260 Y INJECTABLE Primary
Mitomycin Mutamycin J9280 Y INJECTABLE Primary
Mitoxantrone HCL Novantrone J9293 Y INJECTABLE Primary
Moxetumomab pasudotox-tdfk Lumoxiti J9999 Y INJECTABLE Primary
Moxetumomab pasudotox-tdfk Lumoxiti C9045 Y INJECTABLE Primary
Mogamulizumab-kpkc Poteligeo J9999 Y INJECTABLE Primary
Mogamulizumab-kpkc Poteligeo C9038 Y INJECTABLE Primary
Necitumumab Portrazza J9295 Y INJECTABLE Primary
Nelarabine Arranon J9261 Y INJECTABLE Primary
Nivolumab Opdivo J9299 Y INJECTABLE Primary
Obinutuzumab Gazyva J9301 Y INJECTABLE Primary
Octreotide depot Sandostatin J2353 Y INJECTABLE Primary
Octreotide non-depot Sandostatin J2354 Y INJECTABLE Primary
Ofatumumab Arzerra J9302 Y INJECTABLE Primary
Olaratumab Lartruvo J9285 Y INJECTABLE Primary
Omacetaxine Synribo J9262 Y INJECTABLE Primary
Oxaliplatin Eloxatin J9263 Y INJECTABLE Primary
Paclitaxel Nov-Onxol, Taxol J9267 Y INJECTABLE Primary
Paclitaxel (albumin-bound) Abraxane J9264 Y INJECTABLE Primary
Page 3 of 8
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
Panitumumab Vectibix J9303 Y INJECTABLE Primary
Pegaspargase Oncaspar J9266 Y INJECTABLE Primary
Peginterferon, alfa-2a Pegasys J3590 Y INJECTABLE Primary
Peginterferon, alfa-2a Pegasys S0145 Y INJECTABLE Primary
Peginterferon, alfa-2b PegIntron J3590 Y INJECTABLE Primary
Peginterferon, alfa-2b PegIntron S0148 Y INJECTABLE Primary
Peginterferon, alfa-2b Sylatron C9399 Y INJECTABLE Primary
Peginterferon, alfa-2b Sylatron J9999 Y INJECTABLE Primary
Pembrolizumab Keytruda J9271 Y INJECTABLE Primary
Pemetrexed Alimta J9305 Y INJECTABLE Primary
Pentostatin Nipent J9268 Y INJECTABLE Primary
Pertuzumab Perjeta J9306 Y INJECTABLE Primary
Porfimer Sodium Photofrin J9600 Y INJECTABLE Primary
Pralatrexate Folotyn J9307 Y INJECTABLE Primary
Ramucirumab Cyramza J9308 Y INJECTABLE Primary
Rituximab Rituxan J9312 Y INJECTABLE Primary
Rituximab-abbs Truxima C9399 Y INJECTABLE Primary
Rituximab-abbs Truxima J3490 Y INJECTABLE Primary
Rituximab-abbs Truxima J3590 Y INJECTABLE Primary
Rituximab-abbs Truxima J9999 Y INJECTABLE Primary
Rituximab and HyaluronidaseHuman
Rituxan Hycela J9311 Y INJECTABLE Primary
Romidepsin Istodax J9315 Y INJECTABLE Primary
Siltuximab Sylvant J2860 Y INJECTABLE Primary
Sipuleucel-T Provenge Q2043 Y INJECTABLE Primary
Streptozocin Zanosar J9320 Y INJECTABLE Primary
Tagraxofusp-erzs (not available tomarket yet)
Elzonris C9399 Y INJECTABLE Primary
Tagraxofusp-erzs (not available tomarket yet)
Elzonris J9999 Y INJECTABLE Primary
Talimogene Laherparepvec Imlygic J9325 Y INJECTABLE Primary
Temozolomide - inj Temodar J9328 Y INJECTABLE Primary
Temsirolimus Torisel J9330 Y INJECTABLE Primary
Teniposide Vumon Q2017 Y INJECTABLE Primary
Thiotepa Thioplex J9340 Y INJECTABLE Primary
Tocilizumab Actemra J3262 Y INJECTABLE Primary
Topotecan - inj Hycamtin J9351 Y INJECTABLE Primary
Trabectedin Yondelis J9352 Y INJECTABLE Primary
Trastuzumab Herceptin J9355 Y INJECTABLE Primary
Page 4 of 8
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
Trastuzumab-dkst (Not currently onthe Market)
Ogiviri J3490 Y INJECTABLE Primary
Trastuzumab-dkst (Not currently onthe Market)
Ogiviri J3590 Y INJECTABLE Primary
Trastuzumab-dkst (Not currently onthe Market)
Ogiviri J9999 Y INJECTABLE Primary
Trastuzumab-dttb (Not currently onthe Market)
Ontruzant J3490 Y INJECTABLE Primary
Trastuzumab-dttb (Not currently onthe Market)
Ontruzant J3590 Y INJECTABLE Primary
Trastuzumab-pkrb Herzuma J3490 Y INJECTABLE Primary
Trastuzumab-pkrb Herzuma J3590 Y INJECTABLE Primary
Trastuzumab-qyyp Trazimera J3490 Y INJECTABLE Primary
Trastuzumab-qyyp Trazimera J3590 Y INJECTABLE Primary
Trastuzumab and hyaluronidase-oysk
Herceptin Hylecta J3490 Y INJECTABLE Primary
Trastuzumab and hyaluronidase-oysk
Herceptin Hylecta J3590 Y INJECTABLE Primary
Triptorelin Pamoate Trelstar J3315 Y INJECTABLE Primary
Valrubicin Valstar J9357 Y INJECTABLE Primary
Vinblastine Sulfate Velban J9360 Y INJECTABLE Primary
Vincristine Sulfate Oncovin, Vincasar PFS J9370 Y INJECTABLE Primary
Vincristine Sulfate Liposome Marqibo J9371 Y INJECTABLE Primary
Vinorelbine Tartrate Navelbine J9390 Y INJECTABLE Primary
Zivafibercept Zaltrap J9400 Y INJECTABLE Primary
Abemaciclib - oral Verzenio C9399 Y ORAL Primary
Abemaciclib - oral Verzenio J8999 Y ORAL Primary
Abiraterone Acetate - oral Zytiga (not interchangeable with Yonsa) J8999 Y ORAL Primary
Abiraterone Acetate - oral (Notcurrently on the market)
Yonsa (not interchangeable with Zytiga) J8999 Y ORAL Primary
Acalabrutinib Calquence C9399 Y ORAL Primary
Acalabrutinib Calquence J8999 Y ORAL Primary
Afatinib - oral Gilotrif J8999 Y ORAL Primary
Alectinib - oral Alecensa J8999 Y ORAL Primary
All-trans Retinoic Acid - oral Vesanoid, ATRA, Tretinoin J8999 Y ORAL Primary
Altretamine - oral Hexalen J8999 Y ORAL Primary
Apalutamide - oral Erleada J8999 Y ORAL Primary
Axitinib - oral Inlyta J8999 Y ORAL Primary
Bexarotene - oral Targretin J8999 Y ORAL Primary
Binimetinib - oral Mektovi J8999 Y ORAL Primary
Bosutinib - oral Bosulif J8999 Y ORAL Primary
Brigatinib - oral Alunbrig J8999 Y ORAL Primary
Page 5 of 8
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
Cabozantinib - oral Cabometyx J8999 Y ORAL Primary
Cabozantinib - oral Cometriq J8999 Y ORAL Primary
Capecitabine - oral Xeloda (150 mg) J8520 Y ORAL Primary
Capecitabine - oral Xeloda (500 mg) J8521 Y ORAL Primary
Ceritinib - oral Zykadia J8999 Y ORAL Primary
Chlorambucil - oral Leukeran J8999 Y ORAL Primary
Chlorambucil - oral Leukeran S0172 Y ORAL Primary
Cobimetinib - oral Cotellic J8999 Y ORAL Primary
Crizotinib - oral Xalkori J8999 Y ORAL Primary
Dabrafenib - oral Tafinlar J8999 Y ORAL Primary
Dacomitinib - oral Vizimpro J8999 Y ORAL Primary
Dasatinib - oral Sprycel J8999 Y ORAL Primary
Duvelisib - oral Copiktra J8999 Y ORAL Primary
Enasidenib - oral IDHIFA J8999 Y ORAL Primary
Encorafenib - oral Braftovi J8999 Y ORAL Primary
Enzalutamide - oral Xtandi J8999 Y ORAL Primary
Erdafitinib Balversa J8999 Y ORAL Primary
Erlotinib - oral Tarceva J8999 Y ORAL Primary
Estramustine - oral Emcyt J8999 Y ORAL Primary
Etoposide - oral Toposar J8560 Y ORAL Primary
Everolimus - oral Afinitor J8999 Y ORAL Primary
Exemestane - oral Aromasin J8999 Y ORAL Primary
Exemestane - oral Aromasin S0156 Y ORAL Primary
Fluoxymesterone - oral Androxy J8499 Y ORAL Primary
Gefitinib - oral Iressa J8565 Y ORAL Primary
Gilteritinib - oral Xospata J8999 Y ORAL Primary
Glasdegib - oral Daurismo J8999 Y ORAL Primary
Ibrutinib - oral Imbruvica J8999 Y ORAL Primary
Idarubicin - oral Idamycin J8999 Y ORAL Primary
Idelalisib - oral Zydelig J8999 Y ORAL Primary
Imatinib - oral Gleevec J8999 Y ORAL Primary
Imatinib - oral Gleevec S0088 Y ORAL Primary
Ivosidenib - oral Tibsovo J8999 Y ORAL Primary
Ixazomib - oral Ninlaro J8999 Y ORAL Primary
Lapatinib - oral Tykerb J8999 Y ORAL Primary
Larotrectinib - oral Vitrakvi J8999 Y ORAL Primary
Lenalidomide - oral Revlimid J8999 Y ORAL Primary
Page 6 of 8
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
Lenvatinib - oral Lenvima J8999 Y ORAL Primary
Leucovorin - oral , , , J8999 Y ORAL Primary
Lomustine - oral Gleostine, CeeNu, CCNU S0178 Y ORAL Primary
Lorlatinib - oral Lorbrena C9399 Y ORAL Primary
Lorlatinib - oral Lorbrena J8999 Y ORAL Primary
Midostaurin - oral Rydapt J8999 Y ORAL Primary
Mitotane - oral Lysodren J8999 Y ORAL Primary
Neratinib - oral Nerlynx J8999 Y ORAL Primary
Nilotinib - oral Tasigna J8999 Y ORAL Primary
Niraparib - oral Zejula J8999 Y ORAL Primary
Olaparib - oral Lynparza J8999 Y ORAL Primary
Osimertinib - oral Tagrisso J8999 Y ORAL Primary
Palbociclib - oral Ibrance J8999 Y ORAL Primary
Panobinostat - oral Farydak J8999 Y ORAL Primary
Pazopanib - oral Votrient J8999 Y ORAL Primary
Pomalidomide - oral Pomalyst J8999 Y ORAL Primary
Ponatinib - oral Iclusig J8999 Y ORAL Primary
Procarbazine - oral Matulane J8999 Y ORAL Primary
Procarbazine - oral Matulane S0182 Y ORAL Primary
Regorafenib - oral Stivarga J8999 Y ORAL Primary
Ribociclib - oral Kisqali J8999 Y ORAL Primary
Rucaparib - oral Rubraca J8999 Y ORAL Primary
Ruxolitinib - oral Jakafi J8999 Y ORAL Primary
Sonidegib - oral Odomzo J8999 Y ORAL Primary
Sorafenib Tosylate - oral Nexavar J8999 Y ORAL Primary
Sunitinib - oral Sutent J8999 Y ORAL Primary
Talazoparib - oral Talzenna J8999 Y ORAL Primary
Temozolomide - oral Temodar J8700 Y ORAL Primary
Thalidomide - oral Thalomid J8999 Y ORAL Primary
Topotecan - oral Hycamtin J8705 Y ORAL Primary
Trametinib - oral Mekinist J8999 Y ORAL Primary
Trifluridine/Tipiracil - oral Lonsurf J8999 Y ORAL Primary
Vandetanib - oral Caprelsa J8999 Y ORAL Primary
Vemurafenib - oral Zelboraf J8999 Y ORAL Primary
Venetoclax - oral Venclexta J8999 Y ORAL Primary
Vismodegib - oral Erivedge J8999 Y ORAL Primary
Vorinostat - oral Zolinza J8999 Y ORAL Primary
Page 7 of 8
Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class
5-Fluorouracil - topical 5FU Cream, Efudex, Carac, Fluoroplex C9399 Y TOPICAL Primary
5-Fluorouracil - topical 5FU Cream, Efudex, Carac, Fluoroplex J3490 Y TOPICAL Primary
5-Fluorouracil - topical 5FU Cream, Efudex, Carac, Fluoroplex J9999 Y TOPICAL Primary
Bexarotene - topical Targretin gel C9399 Y TOPICAL Primary
Bexarotene - topical Targretin gel J3490 Y TOPICAL Primary
Mechlorethamine - topical Valchlor J9999 Y TOPICAL Primary
Aprepitant Cinvanti J0185 Y INJECTABLE Supportive/Antiemetic
Darbepoetin alfa Aranesp J0881 Y INJECTABLE Supportive
Denosumab Xgeva, Prolia J0897 Y INJECTABLE Supportive
Epoetin alfa Epogen, Procrit J0885 Y INJECTABLE Supportive
Epoetin alfa-epbx Retacrit Q5106 Y INJECTABLE Supportive
Filgrastim Neupogen J1442 Y INJECTABLE Supportive
Filgrastim-aafi Nivestym Q5110 Y INJECTABLE Supportive
Filgrastim-sndz Zarxio Q5101 Y INJECTABLE Supportive
Fosaprepitant Emend J1453 Y INJECTABLE Supportive/Antiemetic
Granisetron Sustol J1627 Y INJECTABLE Supportive/Antiemetic
Lanreotide Somatuline Depot J1930 Y INJECTABLE Supportive
Fosnetupitant/Palonosetron Akynzeo J1454 Y INJECTABLE Supportive/Antiemetic
Palonosetron Aloxi J2469 Y INJECTABLE Supportive/Antiemetic
Pamidronate Disodium Aredia J2430 Y INJECTABLE Supportive
Pegfilgrastim Neulasta J2505 Y INJECTABLE Supportive
Pegfilgrastim-cbqv Udenyca Q5111 Y INJECTABLE Supportive
Pegfilgrastim-jmdb Fulphila Q5108 Y INJECTABLE Supportive
Sargramostim Leukine J2820 Y INJECTABLE Supportive
Tbo-filgrastim Granix J1447 Y INJECTABLE Supportive
Zoledronic Acid Zometa J3489 Y INJECTABLE Supportive
Aprepitant - oral Emend J8501 Y ORAL Supportive/Antiemetic
Netupitant/Palonosetron - oral Akynzeo J8655 Y ORAL Supportive/Antiemetic
Rolapitant - oral Varubi J8670 Y ORAL Supportive/Antiemetic
Telotristat ethyl - oral Xermelo J8999 Y ORAL Supportive
Granisetron - transdermal Sancuso J3490 Y TRANSDERMAL Supportive/Antiemetic
Page 8 of 8
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