List of Medical Protocols, Codes, Key Words and Preauthorization … · 2018-10-17 · Key Words List of Medical Protocols, Codes, Key Words and Preauthorization Information Automated

CPT only copyright American Medical Association. All rights reserved. 1 of 29 Last Update 10/17/18

Name of Corporate Medical ProtocolProtocol

Effective DatePreauthorization

Required? CPT and/or HCPCS Codes Key Words

Actigraphy 04/01/17 Recommended 95803 Actiwatch, Fitbit, Motionlogger, Sleepwatch

Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

06/01/09 04/01/12 04/01/13

Yes, through Case Management

38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232, 38240, 38242, 86812, 86813, 86816, 86817, 86821, 86822, S2140,

S2142, S2150

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

06/01/09 01/01/12 04/01/1307/01/14


38204, 38205, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 86812, 86813, 86816, 86817, 86821, 86822, S2150

Myelofibrosis

Allogeneic Pancreas Transplant

01/01/10 01/01/12 10/01/12 04/01/1307/01/14


S2065, 48550, 48551, 48552, 48554 Pancreas Retransplantation

Ambulance (Emergency)11/01/07 04/01/14

No

A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0888, A0998,

A0999, S9960, S9961

Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

01/01/10 04/01/12 04/01/13 04/01/1401/01/1507/01/1507/01/1607/01/17

No

93268, 93270, 93271, 93272, 93228, 93229, 33282, 33284, 0295T, 0296T, 0297T, 0298T,

0497T, 0498T

MCOT, ZioPatch

List of Medical Protocols, Codes, Key Words and Preauthorization Information






Amniotic Membrane and Amniotic Fluid07/01/1707/01/18

Yes

65778, 65779, Q4100, Q4131, Q4132, Q4133, Q4137, Q4138, Q4139, Q4140, Q4145, Q4148, Q4150, Q4151, Q4153, Q4154, Q4155, Q4156, Q4157, Q4159, Q4160, Q4162, Q4163, Q4168, Q4169, Q4170, Q4171,

Q4173, Q4174Antigen Leukocyte Antibody Test 07/01/14 Recommended 83516 ALCAT

Aqueous Shunts and Stents for Glaucoma

07/01/11 04/01/12 01/01/1304/01/1404/01/1510/01/18

No 0191T, 0253T, 0376T, C1783,

66179, 66183, 66184Express shunt, trabeculectomy

Artificial Intervertebral Disc: Cervical Spine01/01/0810/01/1501/01/17

Yes22856, 22858, 22861, 22864,

0095T, 0098T, 0375TPrestige disc, ProDisc-C, Bryan cervical disc

Artificial Intervertebral Disc: Lumbar Spine 01/01/08 Recommended22857, 22862, 22865, 0163T,

0164T, 0165T Charité Artificial Disc, Intervertebral Disc Arthroplasty,

ProDisc Device; Maverick, FlexiCore

Artificial Pancreas Device Systems07/01/1504/01/1807/01/18

Yes S1034, S1035, S1036, S1037 LGS, hybrid closed loop system

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

07/01/09 01/01/12 01/01/1410/01/1410/01/1510/01/1710/01/18

No29866, 29867, 27415, 27416,

28446 DeNovo NT, DeNovo® ET Live Chondral Engineered Tissue

Graft (Neocartilage), OATS, CAIS, Chondrofix

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

04/01/10 04/01/11 01/01/12 01/01/1404/01/1604/01/18

Yes 27412, S2112, J7330 ACT

Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions

01/01/11 10/01/12 07/01/1310/01/15

No0232T, P9020, S0157, S9055,

G0460, 0481T

Becaplermin, Autologel, Autologous platelet tissue graft, GPS II, Magellan, Autologous Platelet Separator, Safeblood,

Platelet Rich Plasma, Regranex






Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure

03/01/05 10/01/1207/01/14

No93784, 93786, 93788, 93790,

A4670Sphygmomanometry

24 hour ambulatory blood pressure monitoring

Automated Percutaneous and Percutaneous Endoscopic Discectomy

07/15/07 04/01/12 01/01/1410/01/1610/01/18

Recommended62287, 62380, 0274T, 0275T,

C2614DeKompressor or Nucleotome, Percutaneous Discectomy

Autonomic Nervous System Testing04/01/1504/01/16

No95921, 95922, 95923, 95924,

95943

Axial Lumbosacral Interbody Fusion 04/01/12 Recommended 0195T, 0196T, 0309T, 22586 Paracoccygeal, Pre-sacral , or Trans-sacral interbody fusion,

AxiaLIF

Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis

01/01/0705/01/12 04/01/1404/01/15

No 31295, 31296, 31297, C1726 Acclarent, Relieva, Entellus, FinESS

Bariatric Surgery

07/01/10 10/01/11 01/01/1304/01/1404/01/1501/01/1601/01/1704/01/18

No

43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, S2083, 95980, 95981, 95982, 97802,

97803, 97804, 43289

StomaphyX™ devices, EndoCinch, LapBand, REALIZE, Roux-en-Y






Bioengineered Skin and Soft Tissue Substitutes

07/01/1207/01/1307/01/1407/01/1510/01/1510/01/1601/01/1707/01/1707/01/18

Yes

C1878, C9354, C9356, C9358, C9360, C9363, C9364, C9366, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4116, Q4117, Q4118, Q4119, Q4120, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4129, Q4130, Q4131, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4176, Q4177, Q4178,

Q4179, Q4180, Q4181, Q418215040-15261, 15271-15278, 15777

AmnioFix, AlloDerm, Acellular tissue matrix, Allograft, artificial skin, bioengineered skin, skin substitutes

AlloPatch, AlloMax, Avaulta Plus, Biobrane, CellerateRx, Conexa, CRXa, ENDURAgen, E-Z Derm, MediHoney, Mediskin, Repriza, StrataGraft, OrCel, Epifix, Epicel,

TransCyte, Apligraf, Dermagraft, PriMatrix, Oasis wound matrix, Integra Dermal regeneration, Neopatch,

Floweramnioflo, Floweramniopatch, Flowerderm, Revita, Amnio wound, Transcyte, CellerateRX

Biofeedback as a Treatment of Chronic Pain 07/15/07 Recommended 90901, E0746, 90875, 90876

Biofeedback as a Treatment of Fecal Incontinence or Constipation

01/01/10 01/01/12 10/01/1207/01/13

Recommended90875, 90876,

90901, 90911, E0746

Biofeedback as a Treatment of Headache 01/01/10 01/01/11

Recommended 90875, 90876, 90901, E0746

Biofeedback as a Treatment of Urinary Incontinence in Adults

01/01/10 Recommended 90875, 90876, 90901, 90911, E0746

Biofeedback for Miscellaneous Indications

01/01/10 01/01/11 01/01/1207/01/1304/01/16

Recommended 90875, 90876, 90901, E0746

Bioimpedance Devices for Detection and Management of Lymphedema

07/01/18 Recommended 93702

Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

04/01/10 01/01/11 10/01/12 01/01/1307/01/1307/01/15

No 33211, 33213, 33224, 33225Dual Chamber Pacing, Intrathoracic Fluid Monitoring with

biventricular pacing, Resyncronization, cardiac






Blepharoplasty 01/01/13 No15820, 15821, 15822, 15823, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950

Bronchial Thermoplasty 10/01/14 Recommended 31660, 31661 Alair, Asthmatx

Cardiac Rehabilitation in the Outpatient Setting

10/01/10 10/01/1107/01/1307/01/1401/01/1707/01/18

No93797, 93798, G0422, G0423,

S9472

Cardiovascular Risk Panels 04/01/15 No81291, 82465, 82652, 83090, 83698, 83718, 83721, 83880,

84478, 86141, 81599

Carrier Screening for Genetic Diseases04/01/1404/01/18

Yes 81255, 81412

Catheter Ablation as Treatment for Atrial Fibrillation

07/01/11 07/01/1207/01/1510/01/15

No 93656, 93657 Pulmonary vein ablation, Isolation pulmonary vein

Catheter Ablation for Cardiac Arrhythmias 07/01/12 No 93650, 93653, 93654, 93655

Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

07/01/1103/01/1407/01/17

Yes77520, 77522, 77523, 77525,

77299, 77499

Chelation Therapy for Off-Label Uses

01/01/1010/01/1301/01/1501/01/16

NoM0300, J3520, J0470, J0600, S9355,

J0895, 96365, 96366, 96374

EndRate®, Chemical Endarterectomy

Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss

01/01/1507/01/1504/01/16

No 88271 and units >99Anora™ miscarriage test, CombiSNP™ Array for Pregnancy

Loss, CombiBAC™ Array, Natera POC, Progenity lab

Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

10/01/16 Recommended 86152, 86153, 0011M Veridex, NeoLABTM, NeoGenomics

Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)

04/01/18 Recommended 86152, 86153

Closure Devices for Patent Foramen Ovale and Atrial Septal Defects

10/01/0910/01/18

No 93580Aplatzer, Angel wings, ASCOS, GORE HELEX Septal Occluder,

Sideris buttoned device, CardioSeal device, ASD






Cochlear Implant

07/01/11 07/01/1210/01/1307/01/1410/01/1401/01/1701/01/1808/01/18

No

69930, 92601, 92602, 92603, 92604, L8614, L8615, L8616, L8617,

L8618, L8619, V5273, L8627, L8628, L8629

Nucleus Hybrid 24

Cognitive Rehabilitation

01/01/01 01/01/1107/01/1407/01/16

Recommended 97532, 97127

Computed Tomography Perfusion Imaging of the Brain04/01/1501/01/16

Yes 0042T Cerebral perfusion

Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast

10/01/09 Recommended 0159T

Computer-Assisted Navigation for Orthopedic Procedure

07/01/10 07/01/12

Recommended 0054T, 0055T, 20985

Confocal Laser Endomicroscopy 07/01/13 No 43206, 43252, 88375, 0397T

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

04/01/09 04/01/11 04/01/1307/01/1301/01/1407/01/1501/01/18

No for 72 hour testing; Else yes

95250, 95251, S1030, S1031, A9276, A9277,

A9278

GlucoWatch, MiniMed® 530G System-Enlite™ Sensor, Enlite™ Serter, MiniLink Real-Time System, CareLink® Pro

Software for Diabetes, Revel

Continuous Passive Motion in the Home Setting07/01/10 01/01/11 01/01/12

Yes E0935, E0936 CPM, Joint rehabilitation

Cooling Devices Used in the Outpatient Setting 07/01/13 No E0218, E0236 AutoChill, CryoCuff, Game Ready, Hot/Ice Thermal Blanket,

Polar Care Cub

Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy

10/01/10 04/01/12 01/01/13

Recommended 92025 Keratometry

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatological Tumors

07/01/10 01/01/13 01/01/1404/01/18

No19105, 20983, 32994, 50250,

50542, 50593, 0340TCryoablation, Cryocare, CryoGen, CryoHit, SeedNet, Visica

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

07/01/10 Recommended47371, 47381, 47383, 77013,

77022






Cytochrome P450 Genotyping

01/01/10 01/01/1107/01/1307/01/1407/01/1507/01/1607/01/17

No81225, 81226, 81227, 81401, 81402, 81404, 81405, 0028U,

0031U

Amplichip, CYP 450, Pharmacogenomic Testing, Clopidogrel, Plavix, CYP2D6, CYP1A2

Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

04/01/11 04/01/1207/01/15

Yes49999, 58999, 77605, 96446,

96549

Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)

11/01/07 Recommended S2348, 62287 Coblation, Disc Decompression, Laser discectomy, Disc

Nucleoplasty

Deep Brain Stimulation

01/01/10 10/01/1207/01/1407/01/1507/01/18

No

61850, 61863, 61864, 61867, 61868, 61885, 61886, 95970, 95978, 95979, L8679, L8680, L8685, L8686, L8687, L8688

Activa Tremor Control System, Dystonia, Essential Tremor, Parkinson’s Disease

Dermatologic Applications of Photodynamic Therapy

07/01/11 07/01/1207/01/1407/01/15

Recommended 96567, J7308, J7309, 96573, 96574BLU-U Blue Light, CureLight Broadband, Levulan KeraStick,

Metvix

Diagnosis and Management of Idiopathic Environmental Intolerance and Intracellular Micronutrient Analysis

12/05/06 01/01/13 01/01/14

RecommendedNo specific code - 86353 or 88348

might be used

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

07/01/1107/01/1207/01/1310/01/1407/01/1510/01/1510/01/1610/01/18

No

95782, 95783, 95800, 95801, 95806, 95807, 95808, 95810, 95811, A9279, A7047, E0601, E0470, E0471, E0472, E0485, E0486, G0398, G0399, G0400

STOP-BANG

Diagnosis and Treatment of Sacroiliac Joint Pain

09/01/0904/01/12 07/01/1304/01/1401/01/1601/01/1701/01/1807/01/18

Yes27096, 27279, 27280, 27299,

G0259, G0260iFuse






DNA-Based Testing for Adolescent Idiopathic Scoliosis04/01/1201/01/18

Yes 81479, 0004M, 81599ScoliScore, Axial Biotech, Genetic and Prognostic Testing,

scoliosis; Genetic Testing, scoliosis

Dopamine Transporter Imaging With Single-Photon Emission Computed Tomography

01/01/15 Recommended 78607, A9584

Dementia with Lewy Bodies, Parkinsonian Syndromes, Parkinson’s Disease

123I-b-CIT, 123I-FP-CIT, 99mTc-TRODAT-1DaTscan, DAT-SPECT

Dynamic Posturography

07/01/10 04/01/11 04/01/1204/01/13

Recommended 92548 Equitest™, Metitur™, Moving Platform Posturography

Dynamic Spinal Visualization 01/01/09 No 76120, 76125

Cineradiography Digital Motion X ray

VideofloroscopyVideoflourography Videoradiography

Electrical Bone Growth Stimulation of the Appendicular Skeleton

01/01/09 10/01/10 04/01/1204/01/1304/01/14

Yes20974, 20975, E0747,

E0749

Electrical Stimulation for the Treatment of Arthritis 05/01/06 Recommended E0762 BioniCare Bio 1000

Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

01/01/09 10/01/10 07/01/12

Yes E0748, E0749, 20974, 20975

Electromagnetic Navigation Bronchoscopy01/01/1104/01/12 04/01/13

No 31627, A4648 InReach™ or SpiN Drive™ system

Electrostimulation and Electromagnetic Therapy for Treating Wounds

10/01/09 04/01/14

NoE0761, E0769, G0281, G0282,

G0295, G0329 Alternating Current (AC) Electrical Stimulation, High Voltage Pulsed Current (HVPC), Low Intensity Direct Current (LIDC)

Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer

04/01/15 No 31620, 31652, 31653, 31654

Endometrial Ablation 01/01/14 No 58353, 58356, 58563Her Option, Rollerball ablation, Hydro ThermAblator, The

NovaSure

Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus

07/01/10 10/01/1201/01/16

Recommended43257, 43211, 43229, 43254,

43270HALO

Endothelial Keratoplasty 04/01/14 No 65756, 65757 DLEK, DMEK, DSEK, DSAEK, EK, PK






Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

01/01/12 10/01/12 07/01/1401/01/1501/01/1610/01/18

No

35475, 36100, 36215, 36216, 36217, 36218, 37184, 37185, 37218, 61624, 61630, 61635,

61645, 61650, 61651

Neurolink System, Percutaneous Transluminal Angioplasty, Vertebrobasilar Stenosis, Angioplasty, Wingspan Stent

System, penumbra, Merci clot retriever, mechanical embolectomy

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

07/01/10 07/01/12 07/01/1304/01/1401/01/15

Recommended

34812, 34820, 34800, 34802, 34803, 34804, 34805, 34825, 34826, 34839, 75952, 75953, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712,

34713

Stents, AAA, Powerlink Excluder, Zenith, EBT, AneuRx

Endovascular Therapies for Extracranial Vertebral Artery Disease

07/01/15 Recommended 0075T, 0076T V1-V3

Enhanced External Counterpulsation

07/01/09 04/01/1104/01/12 01/01/14

Yes G0166 ECP, EECP

Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies

10/01/1510/01/18

Recommended 81479, 0037U, 0047U, 0057UOnkoMatch by GenPath, FoundationOne CDx (F1CDx),

Guardant 360

Extracorporeal Photopheresis

07/01/1107/01/1301/01/1508/01/18

No 36522

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

07/01/09 01/01/13

No 28890, 0019T, 0101T, 0102TESWT, Epos Ultra, Orbasone, Orbaspec, OssaTron Device®,

SONOCUR®

Extracranial Carotid Artery Stenting

10/15/05 01/01/12 10/01/1208/01/18

No 37215, 37216, 0075T, 0076TACCULINK™ and RX ACCULINK™; Xact® RX; Precise® nitinol;

NexStent®; ProtégéRx® and SpideRx®

Facet Arthroplasty 01/01/12 Recommended 0202T TFAS

Facet Joint Denervation

01/01/10 10/01/1207/01/1307/01/1401/01/16

Yes64633, 64634, 64635, 64636,

64999, 77003 Radiofrequency neurotomy; pulsed radiofrequency, Slnergy,

medial branch block






Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 01/01/13 Recommended

82239, 82492, 82656, 82710, 82715, 82725, 83520, 83630, 83631, 83986, 83993, 84311, 87102, 87328, 87329, 87336,

89160

Digestive Stool Analysis

Fecal Microbiota Transplantation 10/01/14 Yes 44705, G0455Donor feces infusion, Intestinal microbiota transplantation,

Fecal bacteriotherapy

Functional Neuromuscular Electrical Stimulation04/01/1007/01/1307/01/16

Recommended E0764, E0770, 64565, 64580 NMES

Gastric Electrical Stimulation10/01/03 04/01/13

No

64590, 64595, 43647, 43648, 43659, 43881, 43882, 43999, 95980, 95981, 95982, E0765,

L8679, L8680, L8685, L8686, L8687, L8688

Enterra Therapy System; Pacemaker, Gastric

Gender Reassignment Surgery05/01/1507/01/18

Yes

55970, 55980, 56805, 57335or

Various hysterectomy, mastectomy codes, etc: eg. Surgical codes with dx 302.50, 302.51, 302.52, 302.53,

302.85

Gender Dysphoria

Gene Expression Profiling for Cutaneous Melanoma 10/01/18 No 81401 LINC00518, PRAME

Gene Expression Testing in the Evaluation of Patients with Stable Ischemic Heart Disease

01/01/12 01/01/1410/01/1410/01/1601/01/18

No 81493, 81599Gene expression profiling, cardiovascular disease risk; Gene

expression assay, coronary artery disease risk

Gene Expression-Based Assays for Cancers of Unknown Primary

10/01/09 04/01/11 04/01/12 04/01/1304/01/1404/01/1504/01/18

Recommended 81504, 81540, 0019U Pathwork Tissue of unknown origin

General Approach to Evaluating the Utility of Genetic Panels

01/01/1401/01/1501/01/1601/01/17

Yes

81200-81355, 81400-81408, 81479, 81599, 81120, 81121, 81258, 81259, 81269, 81283, 81413,

81414, 0030U, 0046U

Chromosomal Microarray Genetic Testing, Gene Test Panels, Next-Generation Sequencing, Next Gen






General Approach to Genetic Testing

04/01/1104/01/12 01/01/13 01/01/1401/01/1501/01/1601/01/17

Yes

81161, 81200, 81220, 81221, 81222, 81223, 81224, 81242, 81251, 81255, 81287, 81291, 81321, 81322, 81323, 81330, 81331, 81405, 81406, 81407, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, S3800,

S3841, S3842, S3843, S3844, S3845, S3846, S3849, S3850, S3853, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81175, 81176, 81230, 81231, 81247, 81248, 81249, 81328, 81334, 81346, 81361, 81362,

81363, 81364

Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

01/01/14 No81435, 81436, 81445, 81450, 81455, 81471, 81479, 0048U

Genetic Testing for Alpha1-Antitrypsin Deficiency 01/01/1301/01/18

Yes 81332

Genetic Testing for Alzheimer Disease

07/01/03 07/01/1207/01/1407/01/1610/01/17

No S3852, 81401, 81405, 81406Apolipoprotein E (APOE) or Presenilin, TREM2, PSEN,

epsilon 4allele

Genetic Testing for Breast Cancer Gene Expression Prognosis Assay

04/01/10 04/01/11 04/01/12 04/01/1304/01/1401/01/1501/01/1707/01/1701/01/18

YesS3854, 0008M, 81519, 84999,

81520, 81521, 0045U Oncotype testing, Microchip array, MammaPrint, Her,

Her2






Genetic Testing for Cardiac Ion Channelopathies

10/01/0907/01/1401/01/1604/01/18

Yes 81413, 81414, S3861Familion, Long QT Syndrome, Short QT Syndrome, Brugada

Syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia

Genetic Testing for Cystic Fibrosis01/01/1701/01/18

No81220, 81221, 81222, 81223,

81224

Genetic Testing for Developmental Delay and Autism Spectrum Disorder

01/01/1104/01/1207/01/1404/01/1501/01/1601/01/1707/01/1701/01/18

Yes

81228, 81229, 81243, 81244, 81302, 81303, 81304, 81404, 81406, 81470, 81471, S3870,

81415, 81416, 81417

Chromosomal Microarray Analysis, Array Comparative Genomic Hybridization (ACGH), Genomic hybridization, MA,

NGS, MECP2

Genetic Testing for Duchenne and Becker Muscular Dystrophy

07/01/13 07/01/1407/01/1510/01/17

Yes 81161, 81408 DMD, BMD

Genetic Testing for Epilepsy 04/01/16 Yes 81479Genetic Testing for Familal Cutaneous Malignant Melanoma

01/01/11 01/01/12

Recommended 81404 Melaris

Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

04/01/10 04/01/12 04/01/13 04/01/1401/01/17

Yes

81201, 81202, 81203, 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318,

81319, 81403

Adenomatous Polyposis Coli. APC, Familial Adenomatous Polyposis, FAP, BRAF V600E, Colaris test

Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome

10/01/10 04/01/12 04/01/13 04/01/1407/01/1407/01/1501/01/1707/01/1701/01/1808/01/18

Yes81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217,

81406, 81408, 81479 BRCA1 and BRCA2 mutations, CHEK2, ATM, PALB2

Genetic Testing for Hereditary Hearing Loss04/01/1401/01/1501/01/18

Yes81252, 81253, 81254, 81430,

81431GJB2, GJB6

Genetic Testing for Hereditary Hemochromatosis01/01/1301/01/15

Yes 81256






Genetic Testing for Human Leukocyte Genes (HLA) 01/01/17Yes for some

diagnosis

81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381,

81382, 81383

simple sequence, polymerase chain, reverse dot blot hybridization, PCR

Genetic Testing for Lactase Insufficiency 10/01/13 Recommended 81400 Lactotype

Genetic Testing for Leukemia and Lymphoma01/01/1701/01/18

Yes

81162, 81170, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81218, 81219, 81225, 81226, 81217, 81235, 81240, 81241, 81245, 81246, 81256, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81272, 81273, 81275, 81276, 81287, 81301, 81310, 81311, 81313, 81314, 81370-81383,

0023U, 0027U, 0040U, 0049U, 0050U, 0056U

Genetic Testing for Li-Fraumeni Syndrome10/01/1410/01/18

Yes 81405 TP53

Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment


Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders

07/01/1507/01/18

Yes 81405, 81408, 81410, 81411

Genetic Testing for Mental Health Conditions10/01/1404/01/1504/01/16

Yes81225, 81226, 81291, 81401,

81479, 0032U, 0033U

Genomind, LLC, Genecept Assay, STA2R, GeneSight Psychotropic panel, Proove narcotic risk, COMT, HRT2A,

HTR2C

Genetic Testing for Mitochondrial Disorders10/01/1410/01/1510/01/17

Yes81401, 81403, 81440, 81460,

81465Mitochondrial DNA

Genetic Testing for Noninvasive Prenatal Testing 01/01/1701/01/18

Yes0009M, 81420, 81507, 81508, 81509, 81510, 81511, 81512

Down Syndrome, Maternal Plasma DNA testing, Prenatal Detection, MaterniT21™ (Sequenom); verifi® (Verinata Health); Harmony™ (Ariosa Diagnostics); Panorama™

(Natera), Illumina, aneuploigy, massively parallel-sequencing

Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

07/01/1207/01/16

Yes S3865, S3866, 81405, 81406, 81407 HCM

Genetic Testing for PTEN Hamartoma Tumor Syndrome07/01/1307/01/14

Yes 81321, 81322, 81323 ARUP lab, PHTS

Genetic Testing for Statin-Induced Myopathy 01/01/14 No 81400SLCO1B1

Boston Heart Diagnostics, Berkeley Heart Lab






Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

01/01/1401/01/18

Recommended81324, 81325, 81326, 81403, 81404, 81415, 81406, 81479,

81448PMP22

Genetic Testing for Warfarin Dose04/01/201104/01/2018

Recommended G9143, 81227, 81355, 0030UCoumadin®, CYP450. Cytochrome p450, VKORC1, Vitamin K

epoxide reductase subunit C1, Genotyping, Pharmacogenomic Testing

Genetic Testing of CADASIL Syndrome

04/01/12 04/01/1404/01/1504/01/18

Yes 81406 Notch3

Genotype-Guided Tamoxifen Treatment 10/01/12 Recommended 81226

Heart Transplant

04/01/10 04/01/11 04/01/1204/01/14


33940, 33944, 33945

Heart/Lung Transplant

04/01/10 04/01/11 04/01/1204/01/14


33930, 33933, 33935, 33960, 33961

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

06/01/10 07/01/1210/01/1307/01/14


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

10/01/10 10/01/11 07/01/1204/01/13 07/01/1307/01/1407/01/16


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Autoimmune Diseases

06/01/09 04/01/11 04/01/12 04/01/14


38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221,

38240, 38241, 38243, S2150

Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

06/01/09 04/01/12 04/01/13


38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232,

38240, 38241, 38243, S2150

Ependymoblastoma, High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET), Central

Medulloblastoma, Neuroblastoma, Pinealblastoma






Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

10/01/11 07/01/12


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

06/01/09 07/01/1204/01/13


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer

06/01/09 04/01/12 04/01/13


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Hodgkin Lymphoma

06/01/09 04/01/12 04/01/1304/01/18


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

06/01/09 04/01/12 04/01/13


38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232,

38240, 38241, 38243, S2150

Lung Cancer

Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

06/01/09 10/01/11 07/01/12 04/01/13


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome

06/01/09 10/01/11 01/01/14


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation for Primary Amyloidosis

06/01/09 01/01/12 10/01/12


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150






Hematopoietic Cell Transplantation for Solid Tumors of Childhood

06/01/09 04/01/11 01/01/12 06/01/1204/01/1310/01/18


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Ewing’s Sarcoma, Wilms’ Tumor

Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia

01/01/1204/01/13


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors

10/01/10 10/01/11


38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,

S2140, S2142, S2150

Seminoma or testicular cancer high dose chemotherapy

Hip Resurfacing10/01/1210/01/14

No S2118Birmingham Device, Conserve Plus, Cormet System, Surface

Hip ArthroplastyHippotherapy 01/01/05 Recommended S8940 Equine Movement TherapyHomocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease

01/01/10 10/01/1210/01/17

No 83090

Hyperbaric Oxygen Therapy

10/01/10 10/01/11 07/01/1207/01/1307/01/1407/01/1501/01/1607/01/18

Yes 99183, A4575, G0277 HBO

Image-Guided Minimally Invasive Decompression for Spinal Stenosis

01/01/1110/01/1410/01/1710/01/18

Recommended 64999, 0275T, G0276MILD® procedure, Posterior lumbar decompression, Lumbar

spinal stenosis, X-Sten MILD Tool Kit

Immune Cell Function Assay 01/01/11 04/01/12

Recommended 86352 Cylex, ImmuKnow

Implantable Bone-Conduction and Bone-Anchored Hearing Aids

07/01/11 07/01/12 04/01/1301/01/1708/01/18

NoL8690, L8691, L8692, L8693, L8694,

69710, 69711, 69714, 69715, 69717, 69718

BAHA, Otomag Alpha 1 [M], Cordele II, Softband, Divino, Intenso, BP100, AC CROS






Implantable Cardioverter Defibrillators

01/01/06 01/01/12 04/01/1307/01/1401/01/1604/01/18

No

33216, 33217, 33218, 33220, 33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 93260, 93261, 93644, C1721, C1722, C1882, G0448, 0319T, 0320T, 0321T, 0322T, 0323T, 0324T, 0325T, 0326T, 0327T, 0328T

Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease

04/01/13 04/01/1404/01/17

Recommended S1090, 0406T, 0407TPropel, Relieva Stratus MicroFlow, SinuFoam, Sinuva

implant, mometasone furoate

Implantation of Intrastromal Corneal Ring Segments07/01/1008/01/18

No 0099T, 65785 Intacs, Keratoconus

In Vitro Chemoresistance and Chemosensitivity Assays

03/01/06 10/01/1201/01/1601/01/18

RecommendedSeries of lab codes used.

81535, 81536

AntiCancer, Inc, Chemo FX® Assay, Cytoprint, EDR, Extreme Drug Resistance, Histoculture, Oncotech, ChemoFit,

AccuTheranostics, ChemoFX

Ingestible pH and Pressure Capsule01/01/11 10/01/12

Recommended 91112 Smart Pill

Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

01/01/10 01/01/11 01/01/1207/01/1307/01/15

Recommended51715, L8603, L8604, L8605, L8606,

Q3031, 0377T, 55874

Durasphere, Teflon®, Uryx, Tegress, Ethylene Vinyl Alcohol Copolymer, Coaptite®, Calcium H, Macroplastique,

Polydimethylsiloxane, Dextranomer/Hyaluronic Copolymer, Zuidex™ Implace™, Contigen

Intensity-Modulated Radiotherapy: Abdomen and Pelvis07/01/1107/01/1307/01/14

Recommended 77301, 77385, 77386, 77338,

G6015, G6016

Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

07/01/11 01/01/13 01/01/1407/01/15

Recommended 77301, 77385, 77386, 77338,

G6015, G6016

Intensity-Modulated Radiotherapy: Central Nervous System Tumors

10/01/1210/01/1303/01/1407/01/17

No 77301, 77385, 77386, 77338,

G6015, G6016

Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

01/01/0710/01/1310/01/17

Recommended22867, 22868, 22869, 22870,

C1821 X-Stop (X Stop)

Spinous Process Distraction Device






Interspinous Fixation (Fusion) Devices 04/01/13 Recommended 22840, 22851

Affix (Nuvasive), Aileron (Life Spine), Aspen (Lanx), Axle (X-Spine), BacFuse (Pioneer Surgical), BridgePoint (Alphatec),

coflex-F (Paradigm Spine), Inspan (Spine Frontier), PrimaLOK (OsteoMed), Octave, Spire (Medtronic), SP-Fix

(Globus)

Intra-Articular Hyaluronan Injections for Osteoarthritis

04/01/1307/01/1404/01/1504/01/17

NoJ7321, J7323, J7324, J7325, J7326,

J7327, J7328, Q9980, 20610, C9465Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc,

Viscosupplementation

Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas

10/01/0903/01/14

Recommended 64999, A9527 GliaSite, IsoRay

Intradialytic Parenteral Nutrition 07/30/04 Recommended B4164-B5200

Intraoperative Neurophysiologic Monitoring

10/01/1307/01/1407/01/1510/01/17

No92585, 95829, 95867, 95868, 95925-95927, 95930, 95955,95940, 95941, G0453, 0333T

EMG, Somatosensory-evoked potentials, Visual-evoked potentials

Invasive Prenatal (Fetal) Diagnostic Testing04/01/1504/01/18

Yes 81228, 81229, 81405, 81470

Islet Transplantation

10/01/09 10/01/1104/01/1307/01/15


48160, 48999, G0341, G0342, G0343, S2102

Isolated Small Bowel Transplant

04/01/10 04/01/1204/01/13 04/01/1401/01/15


44132, 44133, 44135, 44136, 44715, 44720, 44721

Keratoprosthesis04/01/1010/01/1510/01/16

Recommended 65770, L8609, C1818 Artificial cornea

Kidney Transplant

10/01/09 10/01/11 07/01/1207/01/1301/01/15


50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340,

50360, 50365, 50547

KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

01/01/12 Recommended 81479 KIF6






KRAS, NRAS, and BRAF Variant Analysis in Metastatic Colorectal Cancer

07/01/1207/01/1407/01/1510/01/1607/01/1707/01/18

Yes81210, 81275, 81276, 81311,

81403, 81404, 88363

Laboratory Testing for HIV Tropism

07/01/10 07/01/1207/01/1407/01/15

Recommended 87999 Trofile test for maraviroc, Selzentry, SensiTrop

Laboratory Tests for Heart Transplant Rejection07/01/1307/01/14

Recommended0085T, 86849 81595, 0055U

AlloMap™ (XDx, Inc.)Breath Test, Heartsbreath (Menssana Research)

grade2R/grade 3

Light Therapy for Psoriasis 07/01/16 Yes96900, 96912, 96920, 96921,

96922

Laser Treatment, Photomedex; XTRAC, Targeted Phototherapy, Psoralens with Ultraviolet A (PUVA), VTRAC,

BClear, ExciliteLight Therapy for Vitiligo 07/01/18 Yes 96912, 96999, J8999 Psoralens with Ultraviolet A (PUVA)

Lipid Apheresis 10/01/0907/01/1504/01/18

Recommended 36516, S2120, 0342T LDL or Familial hypercholesterolemia apheresis

Liver Transplant and Combined Liver-Kidney Transplant

01/01/10 01/01/12 04/01/12 04/01/1307/01/1407/01/18


47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144,

47145, 47146, 47147Hepatic Transplant

Low-Level Laser Therapy 04/01/10 04/01/1104/01/17

Recommended S8948, 97026 MicroLight, Low Level Laser, Carpal Tunnel Syndrome

Lung and Lobar Lung Transplant

01/01/10 01/01/12 10/01/1207/01/1307/01/14


32850, 32851, 32852, 32853, 32854, 32855, 32856, S2060, S2061

Lung Volume Reduction Surgery for Severe Emphysema

01/01/11 01/01/1201/01/1508/01/18

No32491, 32672,

G0302, G0303, G0304, G0305

Lysis of Epidural Adhesions 01/01/06 04/01/12 04/01/13

Recommended 62263, 62264, 64999 Racz procedure






Magnetic Resonance Imaging‒Targeted Biopsy of the Prostate

01/01/18 No 55700, 55705, 55706

Magnetic Resonance-Guided Focused Ultrasound

07/01/04 07/01/1307/01/1407/01/15

Recommended 0071T, 0072T, 0398TExAblate 2000

High Intensity Ultrasound Ablation

Magnetoencephalography/Magnetic Source Imaging04/01/11 04/01/12

Recommended 95965, 95966, 95967, S8035 MSI (Magnetic Source Imaging)

Manipulation Under Anesthesia 07/15/09 10/01/1108/01/18

No 22505, 00640

Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders

07/01/10 07/01/12

Recommended 95012, 83987, 94799

Measurement of Serum Antibodies to Infliximab and Adalimumab

04/01/15 Recommended 84999Serum infliximab and antichimeric antibodies, Anser IFX,

Anser ADA, HACA, ATI, ATA, Remicade, Humira, Prometheus

Meniscal Allografts and Other Meniscus Implants 04/01/10 04/01/12 01/01/13

No 29868, G0428 Menaflex

Microprocessor-Controlled Prostheses for the Lower Limb

03/01/09 10/01/11 07/01/1207/01/1308/01/18

NoL5856, L5857, L5858, L5859, L5969,

L5973, L5999 C-Leg, Intelligent Prosthesis, knee, iPED foot prosthesis,

Adaptive knee prosthesis, Power foot or knee, Proprio Foot

Microwave Tumor Ablation 07/01/13 Recommended 32998, 47382, 50592Microwave coagulation therapy, MWA

MTX-180, VivaWave, Tri-Loop, MicroSurgeon, Microsulis, NeuWave Certus 140, Covidien

Miscellaneous Genetic and Molecular Diagnostic Tests10/01/1710/1/18

Recommended 81327 ColoVantage, SEPT9, methylated DNA

Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer

10/01/09 10/01/1107/01/1404/01/1504/01/1610/01/1610/01/1701/01/1804/01/18

No

81235, 88363, 81275, 81403, 88342, 88365, 81404, 81405, 81406, 81210, 88271, 88274,

88275, 84075, 0022U

EGFR, Erlotinib, gefitinib, Iressa, Tarceva, afatinib, ROS1, BRAF






Molecular Markers in Fine Needle Aspirates of the Thyroid

10/01/1510/01/1601/01/1704/01/1807/01/18

Yes81545, 81599, 84999, 0018U,

0026UMutation Analysis, miRInform, Veracyte, Afirma, ThyGenX,

ThyraMIR, Thyroseq

Molecular Testing for the Management of Pancreatic Cysts or Barrett Esophagus

01/01/10 10/01/1210/01/1410/01/16

Recommended 84999, 89240 PathFinderTG

Multigene Expression Assay for Predicting Recurrence in Colon Cancer

01/01/11 10/01/1310/01/16

Recommended 81525, 84999, 88299Microchip Array, Tumor Gene Expression, Colon Cancer Oncotype Test, Colon Cancer Tumor Gene Expression,

ColonPRS, Coloprint, Genefx, OncoDefender

Multimarker Serum Testing Related to Ovarian Cancer

04/01/11 04/01/13 04/01/1404/01/18

Yes 81500, 81503, 0003UProteomic-based testing,

OVA1 or OVA 1, ROMA, Overa

Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis

04/01/15 No87481, 87491, 87512, 87591,

87661, 87999

Myoelectric Prosthetic Components for the Upper Limb

10/01/10 01/01/13 01/01/1408/01/18

No

L6025, L6026, L6715, L6880, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7190,

L7191

Bionic hand, electrically powered prosthesis

Negative Pressure Wound Therapy in the Outpatient Setting

01/01/11 10/01/11 07/01/1207/01/1307/01/1507/01/18

No

E2402, A6550, A7000, A7001, A9272, 97605, 97606, 97607, 97608, K0743, K0744, K0745,

K0746

Wound Vac, Versatile 1™; RENASYS EZ, RENASYS GO

Nerve Graft With Radical Prostatectomy 05/01/06 Recommended 64999 Genitofemoral Nerve Graft, Prostatectomy Neurofeedback 04/01/09 Recommended 90875, 90876, 90901, E0746

Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease

04/01/1704/01/18

No0001M, 0002M, 0003M, 91200,

0346TFibroSpect, FibroSure, Serum Markers, Liver Fibrosis, ASH

test, NASH test, HCV, elastography

Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease

01/01/11 01/01/1207/01/14

Recommended82172, 82664, 83695, 83700, 83701, 83704, 84181, 84999,

0052U

Apolipoprotein A-1, B, or E; HDL Subclass Testing, Lipoprotein A, Small-Density Lipoproteins, Small-Diameter

Lipoproteins

Occipital Nerve Stimulation 01/01/11 Recommended

61885, 61886, 64553, 64568, 64569, 64570, 64999

L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689,

L8679

Occipital Neurostimulation






Occlusion of Uterine Arteries Using Transcatheter Embolization

07/01/11 01/01/1301/01/15

No 37241, 37242, 37243, 37244 Fibroids, UFE, UAE, Leiomyomas

Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus

08/30/0401/01/18

Recommended96570, 96571, J9600,

31641, 43229Hematoporphyrin, Photofrin®, Photochemotherapy,

Photoradiation therapy, Photosensitizing therapy

Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)

07/01/10 01/01/1401/01/1501/01/1601/01/18

No33254, 33255, 33256, 33257, 33258, 33259, 33265, 33266

Hybrid ablationCox-maze, Cox

Optical Coherance Tomography of the Anterior Eye Segment

10/01/11 10/01/1207/01/14

Recommended 92132

AC Cornea OCTAnterior Segment Optical Imaging

Closed Angle GlaucomaVisante OCTStratus OCT

Orthognathic Surgery 01/01/06 01/01/14

No

21083, 21084, 21085, 21088, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21181, 21182, 21183, 21184, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21235, 21240, 21242, 21243, 21247, 21255, 21270,

21275, 21295, 21296

Orthopedic Applications of Platelet-Rich Plasma 10/01/15 Recommended0232T, P9020, S0157, S9055,

G0460, 0481TOrthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)

01/01/11 10/01/1310/01/15

Recommended 38206, 38230, 38232, 38241Mesenchymal stem cells, MSCs, Tissue engineering;

Regenexx™ procedure

Orthoptic/Vision Therapy01/01/10 04/01/1104/01/12

Yes 92065, V2799 Training, eye

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions

07/01/10 07/01/1410/01/1601/01/18

NoE0481, E0483, E0484, A7025,

A7026, S8185, 94669

Flutter device, Acapella, The Vest® Airway clearance System, Percussionaire device, High Frequency Chest

Compression, Intrapulmonary Percussive Ventilation (IPV), Percussionaire, ThAIRapy Vest, Vest Airway clearance, Lung

flute

Outpatient Pulmonary Rehabilitation 07/01/1107/01/1407/01/15

NoS9473, G0237, G0238, G0239, G0302, G0303, G0304, G0305,

G0424






Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

01/01/11 Recommended 36012, 37204Embolization Therapy, Ovarian Vein, for Pelvic Congestion

Syndrome; Positron Emission Tomography

Panniculectomy and Abdominoplasty 01/01/16 Yes 15830, 15834, 15847, 15877

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

01/01/1007/01/14

NoE0740,

53899, G0283

Magnetic therapy, MyoTrac Infiniti, InCare PRS, Pathway, NeoControl, Neotonus Model 1000, Pathway CTS 2000,

InCare PRS

Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation

10/01/1310/01/1410/01/1510/01/1610/01/18

No 22513, 22514, 22515 Kiva

Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy


Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty

04/01/09 Recommended 22526, 22527 ArthroCare, Intradiscal biacuplasty

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

01/01/1607/01/1608/01/18

No 0281T Watchman, lariat

Percuraneous Tibial Nerve Stimulation

01/01/10 10/01/12 10/01/1310/01/1510/01/18

No 64566, 64999, 97014, 97032 PerQ, SANS system, Urgent®, Neuromodulation system

Percutaneous Vertebroplasty and Sacroplasty 10/01/1310/01/1610/01/17

Recommended 22510, 22511, 22512, 0200T,

0201T

Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux

01/01/11 01/01/12 01/01/1410/01/1408/01/18

No 52327, L8603, L8604, L8606 Deflux, VUR

Pharmacogenetic Testing for Pain Management 07/01/15 Yes81225, 81226, 81227, 81291,

81401, 0032U, 0033U

Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines

07/01/10 07/01/1201/01/15

Yes81401, 82491, 81335, 0034U

Modifier 9A Pro-Predict Rx TPMT, Pro-Predict Rx 6MP, Nudix Hydrolase

(NUDT15)

Photodynamic Therapy for Choroidal Neovascularization01/01/1410/01/18

No67221, 67225, J2503, J2778, J3396,

C9257, J0178

Age-Related Macular Degeneration; Bevacizumab, Macugen, Pegaptanib, Ranibizumab,

Visudyne therapy, Lucentis, Verteporfin, Ocular Histoplasmosis






Placental and Umbilical Cord Blood as a Source of Stem Cells

10/01/11Yes, through Case

ManagementS2140, S2142, S2150

Serotonin receptor gene, Dopamine receptor gene, opioid receptor gene

Plasma Exchange

10/01/10 10/01/1210/01/1401/01/16

Yes36514, P9041, P9045, P9046,

P9047 Plasmapheresis, therapeutic apheresis

Plugs for Anal Fistula Repair01/01/1101/01/16

Recommended 46707 Anal fistula plug

Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers

01/01/11 01/01/1204/01/12 04/01/13 04/01/1401/01/17

No

E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673

Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

07/01/1307/01/1401/01/17

No E0676Deep Vein Thrombus

Prevention DVT

Preimplantation Genetic Testing01/01/12 01/01/13 01/01/14

Recommended88271, 88272, 88273, 88274, 88275, 88291, 89290, 89291

Assisted reproductive techniques may be subject to specific contractual restrictions that supersede this Protocol. For

most of our contracts this is an exclusion and therefore PGT is not covered.

PGD

Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia

01/01/11 Recommended No specific codeAutologous Cell Transplant, BioHeart, Heart Disease;

Cellular Cardiomyoplasty, Progenitor cell implantation or transplantation

Prolotherapy 07/01/09 Recommended M0076

Prostatic Urethral Lift07/01/1704/01/18

No 52441, 52442 Urolift, Spanner

Protein and Genetic Testing for Prostate Cancer

01/01/1010/01/1107/01/1507/01/1610/01/1701/01/18

No 81313, 81479, 0021U, 0053U PCA3, uPM3, PCA Test

Quantitative Sensory Testing07/15/0404/01/12

Recommended0106T, 0107T, 0108T, 0109T,

0110T, G0255QST, Medi-Dx 7000™

Neurometer®






Radioembolization for Primary and Metastatic Tumors of the Liver

01/01/11 01/01/12 10/01/12 10/01/1310/01/1410/01/1508/01/18

NoS2095, C2616, 37243, 75894,

77399, 77778, 79445Sir Spheres, TheraSpheres, SIRT, Selective Internal Radiation

Therapy

Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

01/01/10 01/01/13 01/01/14

No20982, 50592, 32998, 50542,

76940RFA

Radiofrequency Ablation of Primary or Metastatic Liver Tumors

01/01/10 01/01/1101/01/1201/01/15

No 47370, 47380, 47382, 76940 RFA

Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer

04/01/15 No78800, 78801, 78802, 78803,

78804, A9507ProstaScint, Indium-111 capromab pendetide

Reconstructive Breast Surgery/Management of Breast Implants

01/01/0604/01/12 04/01/1304/01/14

Yes

11920, 19316, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19499, S2066, S2067,

S2068, L8600

TRAM, Adipose-derived Stem Cells

Reduction Mammaplasty for Breast-Related Symptoms

04/01/1004/01/12 01/01/1404/01/1504/01/16

Yes 19318

Sacral Nerve Neuromodulation/Stimulation

01/01/10 01/01/11 01/01/13 01/01/1401/01/1501/01/16

Recommended

64561, 64581, 64585, 64590, 64595, 95970, 95971, 95972, 95973, A4290, E0745, E1399,

L8680, L8685, L8686, L8687, L8688, L8679

Interstim device

Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer

05/01/1004/01/1201/01/15

No 55700, 55705, 55706, G0416 TTMB, transperineal template-guided mapping

Scintimammography and Gamma Imaging of the Breast and Axilla

08/01/10 10/01/1107/01/1501/01/17

RecommendedS8080, A4641, A4642, A9500,

A9502, A9568, A9572Miraluma®, Radionuclide scanning, breast; Gammagram,

gammogram






Semi-Implantable and Fully Implantable Middle Ear Hearing Aids

10/01/0804/01/1204/01/13

Recommended S2230, V5095, 69799 Vibrant sound bridge, Soundtec Device

Sensory Integration Therapy and Auditory Integration Therapy

10/01/0904/01/1304/01/1504/01/16

Recommended 97533 Auditory integration

Small Bowel/Liver and Multivisceral Transplant

10/01/09 10/01/11 07/01/1207/01/14


44120, 44121, 44132, 44133, 44715, 44720, 44721, 47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144, 47145,

47146, 47147, S2053, S2054, S2055

Spinal Cord and Dorsal Root Ganglion Stimulation

07/01/0907/01/1407/01/1504/01/1710/01/1704/01/18

Yes

63650, 63655, 63685, 63688, 95970, 95971, 95972, 95973,

L8680, L8685, L8686, L8687, L8688, 63661, 63662, 63663, 63664, L8679

Electrical nerve stimulation

Stem Cell Therapy for Peripheral Arterial Disease10/01/1110/01/18

Recommended 0263T, 0264T, 0265T

Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

07/01/11 01/01/1303/01/1407/01/1507/01/16

Recommended

77373, 77435, G0173, G0251, G0339, G0340, 77371, 77372, 77432, 61796, 61797, 61798, 61799, 61800, 63620, 63621,

61781, 61782, 61783

Gamma Knife, Cyber Knife, Helium Radio surgery, Linear Accelerator Radiosurgery, LINAC, Neutron Beam

Radiosurgery, Proton Beam Radiosurgery

Subtalar Arthroereisis 10/01/08 No S2117, 0335TExtraosseous Talotarsal Stabilization

MBA Implant, HyProCureSurgical Treatment of Bilateral Gynecomastia 04/01/15 Yes 19300 Mastectomy

Surgical Treatment of Femoroacetabular Impingement01/01/10 10/01/13

Recommended29914, 29915, 29916, 27299,

29999FAI, CAM or Pincer type impingement, Hip arthroscopy,

femoral or osteochondral osteoplasty, labrum, labral repair

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

10/01/1007/01/1508/01/18

No21199, 41512, 41530, 42145,

42299, S2080, C9727UPPP, LAUP or Pillar Palatal

Surgical Ventricular Restoration 11/01/0704/01/18

Recommended 33548DOR procedure, SAVER, SVR, Ventricular Restoration or

remodeling






Temporomandibular Joint Dysfunction

04/15/08 01/01/11 01/01/12 01/01/13 01/01/1401/01/1501/01/1601/01/17

No

20605, 21010, 21050, 21060, 21070, 21073, 21116, 21240, 21242, 21243, 21480, 21485, 21490, 29800, 29804, 70328, 70330, 70332, 70336, 70486, 70487, 70488, 70350, 70355, E1399, E1700, E1701, E1702, S3900, S8262, 96002, 96003, 96004, 97010, 97024, 97026, 97033, 97810, 97811, 97813,

97814, J7321, J7323, J7324, J7325, J7326

Bitestrip, Gothic Arch Tracing, TMJ Dysfunction (TMD)

Thermography 01/01/00 Recommended 93799

Total Artificial Hearts and Implantable Ventricular Assist Devices

04/01/10 04/01/1104/01/1204/01/13 07/01/1307/01/15

No

0051T, 0052T, 0053T, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33990, 33991, 33992, 33993, 33999, 93750, Q0478, Q0479, L9900, 33927, 33928, 33929

HeartMate I & II

Transanal Radiofrequency Treatment of Fecal Incontinence

10/01/09 Recommended 0288T, 46999 Secca procedure

Transcatheter Aortic Valve Implantation for Aortic Stenosis

07/01/12 04/01/13 04/01/1404/01/1504/01/1708/01/18

No33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368,

33369TAVI, TAVR

Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies

07/01/11 07/01/1207/01/1307/01/1808/01/18

No37241, 37242, 37243, 75894,

Q0083TACE

Transcatheter Mitral Valve Repair04/01/1608/01/18

No 0345T, 33418, 33419 MitraClip

Transcatheter Pulmonary Valve Implantation10/01/12 10/01/13

Recommended 0262T, 33477 Pulmonary valve prosthesis, endovascular implantation

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

07/01/0607/01/1308/15/1401/01/16

Yes 90867, 90868, 90869 NeoPulse, NeuroStar






Transcutaneous Electrical Nerve Stimulation

01/01/10 01/01/1310/01/1401/01/16

No64550, E0720, E0730, E0731, A4595, A4630, A4556, A4557,

A4558 TENS

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease

01/01/0504/01/12 04/01/1304/01/18

Recommended 43210, 43257, 43499 EndoCinch, GERD, NDO Plicator, Esophyx

Transmyocardial Revascularization 04/01/1001/01/1508/01/18

No 33140, 33141 HeartLaser, Eclipse TMR 2000

Treatment of Hyperhidrosis

04/01/10 04/01/12 04/01/1304/01/1401/01/16

Recommended 32664, 97024, 97033, 15876, 15877, 15878, 15879, 26989,

64818, 69676

Sympathectomy, Gustatory, Iontophoresis, Excessive Sweating

Treatment of Tinnitus

01/01/10 01/01/1310/01/1710/01/18

Recommended97014, 97026, 92507, 90832-90838, 90875, 90876, 90901

E0720, S8948Sound Therapy

Treatment of Varicose Veins/Venous Insufficiency

01/01/11 07/01/1307/01/1507/01/1607/01/18

No

36468, 36469, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765,

37766, 37780, 37785, 37799, S2202

Cryoablation, Endoluminal Radiofrequency, Endoluminal Laser Ablation, Endovenous Radiofrequency, Endovenous

Laser Ablation, Radiofrequency Ablation, Saphenous Reflux, Sclerotherapy, Spider Veins, Telangiectatic Veins,

Transilluminated Powered Phlebectomy, Cryosurgery, Diomed 810 nm Surgical Laser; Endoluminal Cryosurgery; Endovenous Laser Therapy (EVLT), Varicose Veins; Erbe

Erbokryo cryosurgical unit RFSFlex; VNUS Closure Procedure; FAST, SEPS Subfascial Endoscopic Perforation

Surgery; TRIVEX system, Microfoam sclerotherapy

Tumor Treating Fields Therapy01/01/1607/01/1610/01/18

Recommended E0766, A4555 NovoTTF-100A, Novocure

Ultrasound Accelerated Fracture Healing Device

04/15/08 10/01/1104/01/1204/01/1304/01/1401/01/18

Yes E0760, 20979 Exogen






Urinary Tumor Markers for Bladder Cancer 01/01/13 No 88120, 88121, 0012M, 0013MBladder Tumor Antigen

(BTA) Test, FISH, ImmunoCyt, NMP-22, Cxbladder

Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer

01/01/1101/01/1501/01/18

No 81479, 81599Genetic Predisposition or Genetic Markers, Breast Cancer,

OncoVue, BREVAGen

Vagus Nerve Stimulation07/01/09 04/01/1301/01/15

No

61885, 61886, 64553, 64568, 64569, 64570, 95974, 95975,

L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689,

0312T, 0313T, 0314T, 0315T, 0316T, 0317T, L8689

NeuroCybernetic Prosthesis (NCP®) system

Vectra® DA Blood Test for Rheumatoid Arthritis 01/01/17 Recommended 81490 ZBC85

Vertebral Axial Decompression 04/15/08 Recommended 97012, S9090 VAX-D, DRX 9000, Accu Spine, Antalgic Trak or spinal

decompression

Vestibular Function Testing 10/01/17 No92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546,

92547

Viscocanalostomy and Canaloplasty04/01/1204/01/18

No 66174, 66175iTrack, Trabectome, Trabeculectomy

Viscoanalostomy

Wearable Cardioverter Defibrillators

10/01/09 04/01/13 04/01/1407/01/1408/01/17

YesK0606, K0607, K0608, K0609,

93745, 93292LifeVest; ICD, Wearable; LifeCor WCD System; AICD,

Wearable Vest, Zoll Live Vest

Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

07/01/17 No81415, 81416, 81417, 81425,

81426, 81427, 0036UExaCT-1

Whole Gland Cryoablation of Prostate Cancer10/01/0910/01/1410/01/15

No 55873

Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon

01/01/10 01/01/11 01/01/13 01/01/1401/01/15

Yes 91110, 91111, 91299, 0335T PillCam and Given AGILE patency, M2A Capsule Camera,

Given Capsule Endoscopy

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