Medicare Advantage Prior Authorization List On behalf of Premera Blue Cross, Advantasure provides prior authorization services. Prior authorization is not a guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable contract terms. Y0134_PriorAuthList_C FVNR 1019 We display one prior authorization list for all Premera Medicare Advantage plans. • Providers: We recommend you review this list before you submit your requests. • If indicated on this PA list, please submit PA requests directly to AIM: www.providerportal.com or Optum: www.providerexpress.com • All DME costing >$1,000 requires prior authorization and is subject to clinical review for medical necessity, even if it is not listed on this Prior Authorization list. • All Part B drugs are now grouped together at the end of the prior authorization list. o HCPCS codes with a cross symbol (†) are for drugs that have prior authorization overlap with Part D formulary. o HCPCS codes with a diamond symbol (◊) are for Part B drugs that require Step Therapy
Medicare Advantage Prior Authorization List
On behalf of Premera Blue Cross, Advantasure provides prior
authorization services. Prior authorization is not a guarantee of
payment. Benefits are based on eligibility at the time of service
and are subject to
applicable contract terms.
Y0134_PriorAuthList_C FVNR 1019
We display one prior authorization list for all Premera Medicare
Advantage plans.
• Providers: We recommend you review this list before you submit
your requests.
• If indicated on this PA list, please submit PA requests directly
to AIM: www.providerportal.com or Optum:
www.providerexpress.com
• All DME costing >$1,000 requires prior authorization and is
subject to clinical review for medical necessity, even if it is not
listed on this Prior Authorization list.
• All Part B drugs are now grouped together at the end of the prior
authorization list.
o HCPCS codes with a cross symbol (†) are for drugs that have prior
authorization overlap with Part D formulary.
o HCPCS codes with a diamond symbol (◊) are for Part B drugs that
require Step Therapy
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
11922 Tattooing, intradermal introduction of insoluble opaque
pigments to correct color defects of skin, including
micropigmentation; each additional 20.0 sq cm, or part thereof
(List separately in addition to code for primary procedure)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15004 Surgical preparation or creation of recipient site by
excision of open wounds, burn eschar, or scar (including
subcutaneous tissues), or incisional release of scar contracture,
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands,
feet and/or multiple digits; first 100 sq cm or 1% of body area of
infants and children
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15271 Application of skin substitute graft to trunk, arms, legs,
total wound surface area up to 100 sq cm; first 25 sq cm or less
wound surface area
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15272 Application of skin substitute graft to trunk, arms, legs,
total wound surface area up to 100 sq cm; each additional 25 sq cm
wound surface area, or part thereof (List separately in addition to
code for primary procedure)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15273 Application of skin substitute graft to trunk, arms, legs,
total wound surface area greater than or equal to 100 sq cm; first
100 sq cm wound surface area, or 1% of body area of infants and
children
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15275 Application of skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area up to 100 sq cm; first 25 sq cm or
less wound surface area
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15277 Application of skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area greater than or equal to 100 sq
cm; first 100 sq cm wound surface area, or 1% of body area of
infants and children
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15771 Grafting of autologous fat harvested by liposuction technique
to trunk, breasts, scalp, arms, and/or legs; 50 cc or less
injectate
1/1/2021 Premera Blue Cross
Provider Portal 855-339-8127
15772 Grafting of autologous fat harvested by liposuction technique
to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc
injectate, or part thereof (List separately in addition to code for
primary procedure)
1/1/2021 Premera Blue Cross
Provider Portal 855-339-8127
15821 Blepharoplasty, lower eyelid; with extensive herniated fat
pad 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 2 of 103 Premera Blue Cross Medicare Advantage Updated
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Code: Description: Effective
15823 Blepharoplasty, upper eyelid; with excessive skin weighting
down lid 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
15833 Excision, excessive skin and subcutaneous tissue (includes
lipectomy); leg 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
15834 Excision, excessive skin and subcutaneous tissue (includes
lipectomy); hip 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
15836 Excision, excessive skin and subcutaneous tissue (includes
lipectomy); arm 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 3 of 103 Premera Blue Cross Medicare Advantage Updated
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Code: Description: Effective
Provider Portal 855-339-8127
Provider Portal 855-339-8127
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
19298 Placement of radiotherapy afterloading brachytherapy
catheters (multiple tube and button type) into the breast for
interstitial radioelement application following partial mastectomy,
includes image guidance
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
19328 Removal of intact breast implant 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
19330 Removal of ruptured breast implant, including implant
contents (e.g., saline, silicone gel) 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
19340 Insertion of breast implant on same day of mastectomy (i.e.,
immediate) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
19342 Insertion or replacement of breast implant on separate day
from mastectomy 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 4 of 103 Premera Blue Cross Medicare Advantage Updated
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Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
19361 Breast reconstruction; with latissimus dorsi flap 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
19364 Breast reconstruction; with free flap (e.g., fTRAM, DIEP,
SIEA, GAP flap) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
19380 Revision of reconstructed breast (e.g., significant removal
of tissue, re-advancement and/or re-inset of flaps in autologous
reconstruction or significant capsular revision combined with soft
tissue excision in implant-based reconstruction)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
20555 Placement of needles or catheters into muscle and/or soft
tissue for subsequent interstitial radioelement application (at the
time of or subsequent to the procedure)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Page 5 of 103 Premera Blue Cross Medicare Advantage Updated
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20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s)
9/16/2020 Premera Blue Cross
Provider Portal 855-339-8127
20561 Needle insertion(s) without injection(s); 3 or more muscles
9/16/2020 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
20975 Electrical Stim Aid Bone Heal Invasive 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
20979 Low intensity ultrasound stimulation to aid bone healing,
noninvasive (nonoperative) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
21082 Impress Custom Prep Palatal Augmentation 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
21086 Impress Custom Prep Auricular Prosth 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
21088 Impress Custom Prep Facial Prosth 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Page 6 of 103 Premera Blue Cross Medicare Advantage Updated
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Provider Portal 855-339-8127
21121 Genioplasty Sliding Osteotomy Single Pie 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
21145 Recon Midface Lefort I Single Graft 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
21196 Recon Mand Ramus Sag Split W/Rigid Rix 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
21210 Graft Bone Nasal Maxilla Malar Area 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
21230 Graft Rib Cart to Face Chin Nose Ear 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
21256 Recon Orbit W/ Osteotomies/Bone Grft 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 7 of 103 Premera Blue Cross Medicare Advantage Updated
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21261 Rep Orbit Hypertelorism Combin Appr 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
21263 Periorbital Osteotomy W/Graft Forehead A 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
21268 Orbit Reposition Unilat W/Graft Intra/Ex 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
21742 Reconstructive Repair of Pectus Excavatum or Carinatum;
Minimally Invasive Approach (Nuss Procedure), Wo Thoracoscopy
5/1/2018 Premera Blue Cross
21743 Reconstructive Repair of Pectus Excavatum or Carinatum;
Minimally Invasive Approach (Nuss Procedure), w Thoracoscopy
5/1/2018 Premera Blue Cross
22100 Partial excision of posterior vertebral component (eg,
spinous process, lamina or facet) for intrinsic bony lesion, single
vertebral segment; cervical
5/1/2018 Premera Blue Cross
22101 Partial excision of posterior vertebral component (eg,
spinous process, lamina or facet) for intrinsic bony lesion, single
vertebral segment; thoracic
5/1/2018 Premera Blue Cross
22102 Partial excision of posterior vertebral component (eg,
spinous process, lamina or facet) for intrinsic bony lesion, single
vertebral segment; lumbar
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
22103 Partial 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)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 8 of 103 Premera Blue Cross Medicare Advantage Updated
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Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
22116 Partial Excision of Vertebral Body for each additional
Vertebral Segment 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
22510 Percutaneous vertebroplasty (bone biopsy included when
performed), 1 vertebral body, unilateral or bilateral injection,
inclusive of all imaging guidance; cervicothoracic
5/1/2018 Premera Blue Cross
22511 Percutaneous vertebroplasty (bone biopsy included when
performed), 1 vertebral body, unilateral or bilateral injection,
inclusive of all imaging B229guidance; lumbosacral
5/1/2018 Premera Blue Cross
22512 Percutaneous vertebroplasty (bone biopsy included when
performed), 1 vertebral body, unilateral or bilateral injection,
inclusive of all imaging guidance; each additional cerv
5/1/2018 Premera Blue Cross
22513 Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy included when
performed) using mechanical device (eg, kyphoplasty), 1
verteb
5/1/2018 Premera Blue Cross
22514 Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy included when
performed) using mechanical device (eg, kyphoplasty), 1
verteb
5/1/2018 Premera Blue Cross
22515 Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy included when
performed) using mechanical device (eg, kyphoplasty), 1
verteb
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 9 of 103 Premera Blue Cross Medicare Advantage Updated
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Provider Portal 855-339-8127
22551 Arthrodesis, Anterior Interbody; Cervical Below C2 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
22633 Arthrodesis, Combined Post Or Postlatl Tech W Post Interbdy
Tech,Incl Lamectmy &/Discectomy,Sgl Interspace & Segmt;
Lumb
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 10 of 103 Premera Blue Cross Medicare Advantage Updated
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Contact for Review:
22634 Arthrodesis, Combind Post Or Postlatl Tech W Post Interbdy
Tech,Incl Lamectmy &/Discectomy,Sgl Interspce & Segmt ;Ea
Addl
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
22841 Internal Spinal Fixation by Wiring of Spinous Processes
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
22842 Instrumentat Post W Segment Wiring 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
22843 Posterior Segmental Instrumentation, 7 To 12 Vertebral
Segments 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
22846 Anterior Instrumentation, 4 To 7 Vertebral Segments 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
22847 Anterior Instrumentation, 8 or More Vertebral Segments
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
22853 Insertion of interbody biomechanical device(s) (eg, synthetic
cage, mesh) with integral anterior instrumentation for device
anchoring (eg, screws, flanges), when performed, to intervertebral
disc space in conjunction with interbody arthrodesis, each
interspace (List separately in addition to code for primary
procedure)
5/1/2018 Premera Blue Cross
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)
5/1/2018 Premera Blue Cross
22856 Total Disc Arthroplasty, Anterior Approach, Including
Discectomy with End Plate Preparation, Single Interspace, Cervical
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 11 of 103 Premera Blue Cross Medicare Advantage Updated
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Provider Portal 855-339-8127
22864 Removal of Total Disc Arthroplasty (Artificial Disc),
Anterior Approach, Single Interspace; Cervical 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
27132 Conversion of previous hip surgery to total hip arthroplasty,
with or without autograft or allograft 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
27446 Arthroplasty, knee, condyle and plateau, medial or lateral
compartment 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
27447 Arthroplasty, knee medical and lateral compartments with or
without patella resurfacing(total knee arthroplasty) 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 12 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
27702 Arthroplasty, Ankle; with Implant (Total) 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
30410 Rhinoplasty, Prim; complete, Extern. Parts 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
30420 Rhinoplasty Primary Maj Septal Rep 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
30450 Rhinoplasty, 2ndary; major revision (nasal tip work and
osteotomies) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
30460 Rhinoplasty for nasal deformity 2ndary to congenital cleft
lip and/or palate, incl columellar lengthening; tip only 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
30462 Rhinoplasty for nasal deformity 2ndary to congenital cleft
lip and/or palate, incl columellar lengthening; tip, septum,
osteotomies
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
30465 Repair of nasal vestibular stenosis (eg, spreader grafting,
lateral nasal wall reconstruction) 7/6/2020 Premera Blue
Cross
Provider Portal 855-339-8127
Page 13 of 103 Premera Blue Cross Medicare Advantage Updated
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30520 Septoplasty or submucous resection, with or without cartilage
scoring, contouring or replacement with graft 7/6/2020 Premera Blue
Cross
Provider Portal 855-339-8127
31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary
sinus ostium (e.g. balloon dilation), transnasal or via canine
fossa
5/1/2018 Premera Blue Cross
31296 Nasal/sinus endoscopy, surgical; with dilation of frontal
sinus ostium (e.g. balloon dilation) 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid
sinus ostium (e.g. Balloon dilation) 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and
sphenoid sinus ostia (e.g. balloon dilation) 8/16/2018 Premera Blue
Cross
Provider Portal 855-339-8127
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Provider Portal 855-339-8127
4/1/2020 Premera Blue Cross
32850 Donor Pneumonectomy(ies) W Prep and Maintenance of Allograft
(Cadaver) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
32852 Lung Transplant, Single, with Cardiopulmonary Bypass 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
32853 Lung Transplant, Double (Sequential or En Bloc); Without
Cardpulm Bypass 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
32854 Lung Transplant, Double (Sequential or En Bloc); with
CardPulm Bypass 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 14 of 103 Premera Blue Cross Medicare Advantage Updated
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32855 Backbench Standard Preparation Of Cadaver Donor Lung
Allograft; Unilateral 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
32856 Backbench Standard Preparation Of Cadaver Donor Lung
Allograft; Bilateral 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
33206 Insertion of new or replacement of permanent Pacemaker with
transvenous electrode(s) 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33207 Insertion of new or replacement of permanent Pacemaker with
transvenous electrode(s) 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33208 Insertion of new or replacement of permanent Pacemaker with
trans venous electrode(s) 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33210 Insertion or replacement of temporary lead/catheter – single
chamber lead 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33212 Insertion of Pacemaker pulse generator only; with existing
single lead 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33213 Insertion of Pacemaker pulse generator only; dual chamber
6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33216 Insertion of a transvenous electrode, single lead 6/4/2019
Premera Blue Cross
Provider Portal 855-339-8127
33217 Insertion of transvenous electrodes, dual leads 6/4/2019
Premera Blue Cross
Provider Portal 855-339-8127
33221 Insertion of pacemaker pulse generator only; with existing
multiple leads 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33224 Insertion of pacing electrode, cardiac venous system, for
left ventricular pacing, with attachment to previously placed
pacemaker or implantable defibrillator pulse generator (including
revision of pocket, removal, insertion, and/or replacement of
existing generator)
6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
Page 15 of 103 Premera Blue Cross Medicare Advantage Updated
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Contact for Review:
33225 Insertion of pacing electrode, cardiac venous system, for
left ventricular pacing, at time of insertion of implantable
defibrillator or pacemaker pulse generator (eg, for upgrade to dual
chamber system) (List separately in addition to code for primary
procedure)
6/4/2019 Premera Blue Cross
33230 Insertion of implantable defibrillator pulse generator only;
with existing dual leads 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33231 Insertion of implantable defibrillator pulse generator only;
with existing multiple leads 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
33240 Insertion of implantable defibrillator pulse generator only;
with existing single lead 6/4/2019 Premera Blue Cross
Provider Portal 855-339-8127
6/4/2019 Premera Blue Cross
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
33935 Heart-Lung Transplant W Recipient Cardi/ 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
33944 Backbench Standard Preparation Of Cadaver Donor Heart
Allograft 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
33945 Heart transplant, w/or without recipient cardiectomy 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 16 of 103 Premera Blue Cross Medicare Advantage Updated
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Provider Portal 855-339-8127
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
34844 Endovascular repair of visceral aorta (eg, aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma,
or traumatic disruption) by deployment of a fenestrate; including
four or more visceral artery endoprostheses (superior mesenteric,
B388celiac and/or renal artery[s])
5/1/2018 Premera Blue Cross
34845 Endovascular repair of visceral aorta and infrarenal
abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic
disruption
5/1/2018 Premera Blue Cross
34846 Endovascular repair of visceral aorta and infrarenal
abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic
disruption
5/1/2018 Premera Blue Cross
34847 Endovascular repair of visceral aorta and infrarenal
abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic
disruption)
5/1/2018 Premera Blue Cross
34848 Endovascular repair of visceral aorta and infrarenal
abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic
disruption)
5/1/2018 Premera Blue Cross
36468 Injection(s) of sclerosant for spider veins (telangiectasia),
limb or trunk 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 17 of 103 Premera Blue Cross Medicare Advantage Updated
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36473 Endovenous ablation therapy of incompetent vein, extremity,
inclusive of all imaging guidance and monitoring, percutaneous,
mechanochemical; first vein treated
10/16/2018 Premera Blue Cross
36474 Endovenous ablation therapy of incompetent vein, extremity,
inclusive of all imaging guidance and monitoring, percutaneous,
mechanochemical; subsequent vein(s) treated in a single extremity,
each through separate access sites (List separately in addition to
code for primary procedure)
10/16/2018 Premera Blue Cross
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
36482 Endovenous ablation therapy of incompetent vein, extremity,
by transcatheter delivery of a chemical adhesive (eg, cyanoa
7/6/2020 Premera Blue Cross
Provider Portal 855-339-8127
36483 Endovenous ablation therapy of incompetent vein, extremity,
by transcatheter delivery of a chemical adhesive (eg, cyanoa
7/6/2020 Premera Blue Cross
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
37700 Ligation and division of long saphenous vein at
saphenofemoral junction, or distal interruptions 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
37718 Ligation, division, and stripping, short saphenous vein
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
37722 Ligation, division, and stripping, long (greater) saphenous
veins from saphenofemoral junction to knee or below 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
37735 Ligation & Strip Saphen+ulcer Unil 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Page 18 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Provider Portal 855-339-8127
Provider Portal 855-339-8127
37765 Stab Phlebectomy of Varicose Veins, One Extremity; 10-20 Stab
Incisions 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
37766 Stab Phlebectomy of Varicose Veins, One Extremity; More Than
20 Incisions 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
37780 Ligation and division of short saphenous vein at
saphenopopliteal junction (separate procedure) 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
37785 Ligation 2ndary Varicose Vein Unilateral 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
38204 Management of Recipient Hematopoietic Progenitor Cell Donor
Search and Cell Acquisition 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 19 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Provider Portal 855-339-8127
38212 Transplant Preparation of Hematopoietic Progenitor Cells; Red
Blood Cell Removal 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
38230 Harvest Bone Marrow For Transplant 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
38240 Bone Marrow Trans plantation; Allogenic 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
43644 Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric
Bypass And Roux -En-Y Gastroenterostomy (Roux Limb <= 150
Cm)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 20 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
43846 Gastric Bypass W/Roux-En-Y- Morbid Obesity 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Page 21 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Contact for Review:
43847 Gstrc Restricve Prcd w Gstrc Byps F Morbid Obesty; w/Sml
Bowel Rcnstn 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
43848 Revision of Gastrc Restrictive Prcd For Morbid Obesity
(Separate Prcd) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
43882 Revision or Removal of Gastric Neurostimulator Electrodes,
Antrum, Open 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
44133 Donor Enterectomy, Open, w Allograft Prep & Maintenance;
Living Donor 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
47140 Donor Hepatectomy, with Preparation and Maintenance of
Allograft, Living Donor; Left Lateral Segment Only 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Page 22 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
47141 Donor Hepatectomy, with Preparation and Maintenance of
Allograft, Living Donor; Total Left Lobectomy 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
47142 Donor Hepatectomy, with Preparation and Maintenance of
Allograft, Living Donor; Total Right Lobectomy 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
47143 Backbench Standard Preparation Of Cadaver Donor Whole Liver
Graft; Without Trisegment Or Lobe Split 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
47144 Backbench Standard Preparation Of Cadaver Donor Whole Liver
Graft; W Trisegment Split Of Graft Into Two Partial Grafts
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
47145 Backbench Standard Preparation Of Cadaver Donor Whole Liver
Graft; With Lobe Split Of Graft Into Two Partial Grafts 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
47146 Backbench Reconstruction Of Cadaver Or Living Donor Liver Gr
aft Prior To Allotransplantation; Venous Anastomosis, Each
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
47147 Backbench Reconstruction Of Cadaver Or Living Donor Liver
Graft Prior To Allotransplantation; Arterial Anastomosis,
Each
5/1/2018 Premera Blue Cross
47370 Laparoscopy, Surgical, Ablation Of One Or More Liver
Tumor(S); Radiofrequency 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
47371 Laparoscopy, Surgical, Ablation Of One Or More Liver
Tumor(S); Cryosurgical 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
47380 Ablation, Open, Of One Or More Liver Tumor(S); Radiofrequency
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
47381 Ablation, Open, Of One Or More Liver Tumor(S); Cryosurgical
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 23 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
47383 Ablation, 1 or more liver tumor(s), percutaneous,
cryoablation 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
48552 Backbench Reconstruction Of Cadaver Donor Pancreas Allograft
Prior To Transplantation, Venous Anastomosis, Each 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
48556 Removal of Transplanted Pancreatic Allograft 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
50320 Donor Nephrectomy from Living Donor,Unil 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
50323 Backbench Standard Preparation Of Cadaver Donor Renal
Allograft 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
50325 Backbench Standard Preparation Of Living Donor Renal
Allograft (Open Or Laparoscopic) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
50327 Backbench Reconstruction Of Cadaver Or Living Donor Renal
Allograft Prior To Transplantation; Venous Anastomosis, Each
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
50328 Backbench Reconstruction Of Cadaver Or Living Donor Renal
Allograft Prior To Transplantation; Arterial Anastomosis,
Each
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
50329 Backbench Reconstruction Of Cadaver Or Living Donor Renal
Allograft Prior To Transplantation; Ureteral Anastomosis,
Each
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 24 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
53860 Transurethral Radiofrequency Micro- Remodeling Of The Female
Bladder Neck And Proximal Urethra 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 25 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
55873 Cryosurgical Ablation of the Prostate (Incl Ultrasonic Probe
Placement) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
55875 Transperineal placement of needles or catheters into prostate
for interstitial radioelement application, with or without
cystoscopy
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
55920 Placement of needles or catheters into pelvic organs and/or
genitalia (except prostate) for subsequent interstitial
radioelement application
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
57155 Insertion of uterine tandem and/or vaginal ovoids for
clinical brachytherapy 1/1/2019 AIM Specialty Health AIM Provider
Portal
866-666-0776
57156 Insertion of a vaginal radiation afterloading apparatus for
clinical brachytherapy 1/1/2019 AIM Specialty Health AIM Provider
Portal
866-666-0776
Provider Portal 855-339-8127
58346 Insertion of Heyman capsules for clinical brachytherapy
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
61850 Twist drill or burr hole(s) for implantation of
neurostimulator electrodes, cortical 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
61863 Burr Hole Craniotomy with Implantation of Subcortical
Electrode Array, wo Intraop Microelectrode Recording; First Array
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
61864 Burr Hole Craniotomy w Implantation of Subcortical Electrode
Array, wo Intraop Microelectrode Recording; ea addl Array
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
61867 Burr Hole Craniotomy with Implantation of Subcortical
Electrode Array, w Intraop Microelectrode Recording; First Array
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
61868 Burr Hole Craniotomy w Implantation of Subcortical Electrode
Array, w Intraop Microelectrode Recording; ea addl Array 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
Page 26 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Provider Portal 855-339-8127
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 discography and/or epidural
injection(s) at the treated level(s), when performed, single or
multiple levels, lumbar
5/1/2018 Premera Blue Cross
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Provider Portal 855-339-8127
63003 Decompress Spine <2 Seg Thoracic 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63016 Decompress Spine >2 Seg Thoracic 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Page 27 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Provider Portal 855-339-8127
63020 Exc Iv Disk Cervical Unilat 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
63030 Exc Iv Disk Lumbar Unilat 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
63035 Exc Iv Disk Cervical/Lumb >1 Space 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63040 Laminotomy W Dec Nrv Rts;reex;cerv 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63042 Laminotomy W Dec Nrv Rts;reex;lumb 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63043 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Cerv
Interspace 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
63044 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Lumb
Interspace 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63050 Laminoplasty, Cervical, With Decompression Of The Spinal
Cord, Two Or More Vertebral Segments 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Page 28 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Contact for Review:
63051 Laminoplasty, Cerv, W Decompression Of Spinal Cord, 2 Or >
Verteb Segments; W Reconstruction Of Posterior Bony Elements
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63057 Decomp Spine Transpedic-Ea Add Seg 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63064 Decompress Spine Costoverteb 1 Seg 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63066 Decomp Spine Costoverteb-Ea Add Seg 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63076 Exc Iv Disk Ant Cervical >1 Seg 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63078 Exc Iv Disk Ant Thoracic-Ea Add Seg 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63082 Vert Corpectomy, Part/Comp.; anter. approach w/
decompression; cerv, each additional segment 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Page 29 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Contact for Review:
63086 Corpecto Verteb Thoracic Ea Add Seg 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63191 Section Spinal Accessory Nerve Unil 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63194 Cordotomy Unilat 1 Stage Cervical 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63195 Cordotomy Unilat 1 Stage Thoracic 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63196 Cordotomy Bilat 1 Stage Cervical 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63197 Laminect W Cordotomy;both Tracts;1 Stg;t 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
Page 30 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
63198 Cordotomy Bilat 2 Stage Cervical 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63266 Exc Les Intraspin Extradur- Thoracic 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63271 Exc Les Intraspin Intradur- Thoracic 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63275 Lam,Bx/Exc Intrasp.Neo;e xtra d ur, Ce r 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
63276 Exc Intraspin Neopl Extradur- Thorac 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63281 Exc Intraspin Neopl Extramed- Thorac 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Page 31 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
63285 Lam,Bx/Exc In.Neo;intrad ur, Im, Cerv 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
63286 Exc Intraspin Neopl Intramed- Thorac 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
63295 Osteoplastic Reconstruction of Dorsal Spinal Elements,
Following Primary Intraspinal Procedure (List separately in
addition to code for primary procedure)
5/1/2018 Premera Blue Cross
63300 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment;
extradural, cervical
5/1/2018 Premera Blue Cross
63301 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment;
extradural, thoracic by transthoracic approach
5/1/2018 Premera Blue Cross
63302 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment;
extradural, thoracic by thoracolumbar approach
5/1/2018 Premera Blue Cross
63304 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment;
intradural, cervical
5/1/2018 Premera Blue Cross
63305 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment;
intradural, thoracic by transthoracic approach
5/1/2018 Premera Blue Cross
63306 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment;
intradural, thoracic by thoracolumbar approach
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
63307 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment;
intradural, lumbar or sacral by transperitoneal or retroperitoneal
approach
5/1/2018 Premera Blue Cross
63308 Vertebral corpectomy (vertebral body resection), partial or
complete, for excision of intraspinal lesion, single segment; each
additional segment (List separately in addition to codes for single
segment)
5/1/2018 Premera Blue Cross
866-666-0776
Page 32 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
63685 Insertion or replacement of spinal neurostimulator pulse
generator or receiver, direct or inductive coupling 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
63688 Revision or removal of implanted spinal neurostimulator pulse
generator or receiver 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
64480 Injection(s), anesthetic agent(s) 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)
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
64484 Injection(s), anesthetic agent(s) 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)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
64491 Injection(s), diagnostic or therapeutic agent, paravertebral
facet (zygapophysial) 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)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
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)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Page 33 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
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)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
64495 Injection(s), diagnostic or therapeutic agent, paravertebral
facet (zygapophyseal) joint (or B513nerves innervating that joint)
with image guidance (fluoroscopy or CT), lumbar or s acral; third
and any additional level(s) (List separately in addition to code
for primary procedure)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
866-666-0776
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
64568 Incision for implantation of cranial nerve (eg, vagus nerve)
neurostimulator electrode a+B570rray and pulse generator 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
64569 Revision or replacement of cranial nerve (eg, vagus nerve)
neurostimulator electrode array, including connection to existing
pulse generator
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator
electrode array and pulse generator 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
64581 Incision for implantation of neurostimulator electrode array;
sacral nerve (transforaminal placement) 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
64595 Revision/removal of periph or gastric neurostimulator pulse
generator or receiver 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 34 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
64612 Dest Neurolytic Agent; Muscle Enervated 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
64616 Chemodenervation of muscle(s); neck muscle(s), excluding
muscles of the larynx, unilateral (eg, for cervical dystonia,
spasmodic torticollis)
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
64633 Destruction by neurolytic agent, paravertebral facet joint
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or
thoracic, single facet joint
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
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)
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
64635 Destruction by neurolytic agent, paravertebral facet joint
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or
sacral, single facet joint
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
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)
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
64642 Chemodenervation of one extremity; 1-4 muscle(s) 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
64643 Chemodenervation of one extremity; each additional extremity,
1 -4 muscle(s) (List separately in addition to code for primary
procedure)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
64644 Chemodenervation of one extremity; 5 or more muscle(s)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
64645 Chemodenervation of one extremity; each additional extremity,
5 or more muscle(s) (List separately in addition to code for
primary procedure)
5/1/2018 Premera Blue Cross
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
Page 35 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Contact for Review:
64647 Chemodenervation of trunk muscle(s); 6 or more muscle(s)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
64650 Chemodenervation of eccrine glands; both axillae 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp,
face, neck), per day 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
66820 Discission of secondary membranous cataract (opacified
posterior lens capsule and/or anterior hyaloid); stab incision
technique (Ziegler or Wheeler knife) 4/1/2020
Premera Blue Cross Provider Portal 855-339-8127
66821 Discission of secondary membranous cataract (opacified
posterior lens capsule and/or anterior hyaloid); laser surgery (eg,
YAG laser) (1 or more stages)
4/1/2020 Premera Blue Cross
66830 Removal of secondary membranous cataract (opacified posterior
lens capsule and/or anterior hyaloid) with corneo- scleral section,
with or without iridectomy (iridocapsulotomy, iridocapsulectomy)
4/1/2020
Premera Blue Cross Provider Portal 855-339-8127
66840 Removal of lens material; aspiration technique, 1 or more
stages
4/1/2020 Premera Blue Cross
Premera Blue Cross Provider Portal 855-339-8127
66852 Removal of lens material; pars plana approach, with or
without vitrectomy
4/1/2020 Premera Blue Cross
4/1/2020 Premera Blue Cross
4/1/2020 Premera Blue Cross
Provider Portal 855-339-8127
66940 Removal of lens material; extracapsular (other than 66840,
66850, 66852) 4/1/2020 Premera Blue Cross
Provider Portal 855-339-8127
Page 36 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Extracapsular cataract removal with insertion of intraocular lens
prosthesis (1-stage procedure), manual or mechanical technique (eg,
irrigation and aspiration or phacoemulsification), complex,
requiring devices or techniques not generally used in routine
cataract surgery (eg, iris expansion device, suture support for
intraocular lens, or primary posterior capsulorrhexis) or performed
on patients in the amblyogenic developmental stage
4/1/2020 Premera Blue Cross
4/1/2020 Premera Blue Cross
Provider Portal 855-339-8127
67218 Destruction of localized lesion of retina (eg, macular edema,
tumors), 1 or more sessions; radiation by implantation of source
(includes removal of source)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal
approach) 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
67901 Repair of blepharoptosis; frontalis muscle technique with
suture or other material (eg, banked fascia) 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
67906 Repair of blepharoptosis; superior rectus technique with
fascial sling (includes obtaining fascia) 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 37 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
69930 Cochlear Device Implantation, W/Wo Masto 5/1/2018 Premera
Blue Cross
Provider Portal 855-339-8127
70336 MRI of the Temporomandibular Joint(s) 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
70450 CT of head, without contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
70460 CT of head, with contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
70470 CT of head, without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70480 CT of orbit, sella or posterior fossa and outer, middle or
inner ear, without contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
70481 CT of orbit, sella or posterior fossa and outer, middle or
inner ear, with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
70482 CT of orbit, sella or posterior fossa and outer, middle or
inner ear, without contrast, followed by re-imaging with contrast
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70486 CT of maxillofacial area, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
70487 CT of maxillofacial area, with contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
70488 CT of maxillofacial area, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
70490 CT, soft tissue neck, without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
70491 CT, soft tissue neck, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
Page 38 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Contact for Review:
70492 CT, soft tissue neck, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70498 CTA, neck, with contrast material(s), including noncontrast
images, if performed, and image post- processing 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
70540 MRI orbit, face and neck, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
70542 MRI orbit, face and neck, with contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
70543 MRI orbit, face and neck, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
866-666-0776
70545 Magnetic resonance angiography, head, with contrast 1/1/2018
AIM Specialty Health AIM Provider Portal
866-666-0776
70546 Magnetic resonance angiography, head, without contrast,
followed by re- imaging with contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
70547 MRA, neck, without contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
70548 MRA, neck, with contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
70549 MRA, neck, without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
70551 MRI Head, without contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
Page 39 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
70552 MRI Head, with contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
70553 MRI Head, without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
866-666-0776
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
71271 Computed tomography, thorax, low dose for lung cancer
screening, without contrast material(s) 1/1/2021 AIM Specialty
Health AIM Provider Portal
866-666-0776
71275 CTA of chest (non-coronary), with contrast material(s),
including non- contrast images, if performed, and image post-
processing
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
71550 MRI chest, without contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
71551 MRI chest, with contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
71552 MRI chest, without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
71555 MRA of chest (excluding the myocardium) without contrast,
followed by re-imaging with contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
Page 40 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
72125 CT of cervical spine, without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72126 CT of cervical spine, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72127 CT of cervical spine, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
72128 CT of thoracic spine, without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72129 CT of thoracic spine, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72130 CT of thoracic spine, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
72131 CT of lumbar spine, without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72132 CT of lumbar spine, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72133 CT of lumbar spine, without contrast, followed by re-imaging
with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
72141 MRI of cervical spine, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
72142 MRI of cervical spine, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72146 MRI of thoracic spine, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
72147 MRI of thoracic spine, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
Page 41 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
72148 MRI of lumbar spine, without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72149 MRI of lumbar spine, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
72156 MRI of cervical spine, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
72157 MRI of thoracic spine, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
72158 MRI of lumbar spine, without contrast, followed by re-imaging
with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
72159 Magnetic resonance angiography of spinal canal 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72192 CT of pelvis, without contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
72193 CT of pelvis, with contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
72194 CT of pelvis without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
72195 MRI of pelvis, without contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
72196 MRI of pelvis, with contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
72197 MRI of pelvis, without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Page 42 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
866-666-0776
73200 CT upper extremity, without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
73201 CT upper extremity, with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
73202 CT upper extremity, without contrast, followed by re-imaging
with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73218 MRI upper extremity, non-joint, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
73219 MRI upper extremity, non-joint, with contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
73220 MRI upper extremity, non-joint, without contrast, followed by
re- imaging with contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
73221 MRI upper extremity, any joint, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
73222 MRI upper extremity, any joint, with contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
73223 MRI upper extremity, any joint, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
73225 Magnetic resonance angiography, upper extremity, without and
with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
73700 CT lower extremity without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
Page 43 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
73701 CT lower extremity with contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
73702 CT lower extremity without contrast, followed by re-imaging
with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73718 MRI lower extremity, other than joint, without contrast
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
73719 MRI lower extremity, other than joint, with contrast 1/1/2018
AIM Specialty Health AIM Provider Portal
866-666-0776
73720 MRI lower extremity, other than joint, without contrast
followed by re- imaging with contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
73721 MRI lower extremity, any joint, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
73722 MRI lower extremity, any joint, with contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
73723 MRI lower extremity, any joint, without contrast followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
73725 Magnetic resonance angiography, lower extremity, without and
with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
74150 CT abdomen; without contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
74160 CT abdomen; with contrast 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
74170 CT abdomen; without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Page 44 of 103 Premera Blue Cross Medicare Advantage Updated
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Code: Description: Effective
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74176 CT of abdomen and pelvis, without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
74177 CT of abdomen and pelvis, with contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
74178 CT of abdomen and pelvis, without contrast, followed by
re-imaging with contrast 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
74181 MRI of abdomen, without contrast 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
74182 MRI of abdomen, with contrast 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
74183 MRI of abdomen, without contrast, followed by re-imaging with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74185 Magnetic resonance angiography, abdomen; without or with
contrast 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
74261 Diagnostic CT colonography without contrast 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
74262 Diagnostic CT colonography with contrast including
non-contrast images if performed 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
866-666-0776
74712 Magnetic resonance (eg, proton) imaging, fetal, including
placental and maternal pelvic imaging when performed; single or
first gestation
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
Page 45 of 103 Premera Blue Cross Medicare Advantage Updated
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Code: Description: Effective
75557 Cardiac MRI for morphology and function, without contrast
material 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75559 Cardiac MRI for morphology and function, without contrast
material, with stress imaging 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
75561 Cardiac MRI for morphology and function, without contrast
material, followed by contrast material 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
75563 Cardiac MRI for morphology and function, without contrast
material, followed by contrast material with stress imaging
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75571 Computed tomography, heart, without contrast material, with
quantitative evaluatio n of coronary artery calcium 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
75572 Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology (including 3-D image
post-processing, assessment of cardiac function, and evaluation of
venous structures if performed)
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75573 Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology in the setting of
congenital heart disease (including 3-D post-processing, assessment
of left ventricular cardiac function, right ventricular structure
and function and evaluation of venous structures, if
performed)
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
75574 Computed tomographic angiography, heart, coronary arteries
and bypass grafts (where present), with contrast material,
including 3-D image post- processing (including evaluation of
cardiac structure and morphology, assessment of cardiac function,
and evaluation of venous structures, if performed)
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
76376 3D rendering w/ interpretationand reporting of CT MRI, US or
other Tomographyic modality with image postprocessing under
concurrent supervision
5/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
76380 CT, limited or localized follow-up study 5/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
76390 Magnetic Resonance Spectroscopy (MRS) 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
866-666-0776
Page 46 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
77014 CT guidance for placement of radiation therapy fields
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77046 MRI Breast Without Contrast Material Unilateral AIM Specialty
Health
AIM Provider Portal 866-666-0776
77047 MRI Breast Without Contrast Material Bilateral AIM Specialty
Health
AIM Provider Portal 866-666-0776
77048 MRI Breast W/Out & With Contrast W/Cad Unilateral AIM
Specialty Health
AIM Provider Portal 866-666-0776
77049 MRI Breast Without & With Contrast W/Cad Bilateral AIM
Specialty Health
AIM Provider Portal 866-666-0776
77078 Computed tomography, bone mineral density study, 1 or more
sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
77084 MRI of bone marrow blood supply 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77316 Brachytherapy isodose plan; simple (1-4 sources or 1
channel), includes basic dosimetry calculations (Do not bill 77300)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77317 Brachytherapy isodose plan; intermediate (5-10 sources or
2-12 channels), includes basic dosimetry calculation (Do not bill
77300)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77318 Brachytherapy isodose plan; complex (over 10 sources or over
12 channels), includes basic dosimetry calculations (Do not bill
77300)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Page 47 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
866-666-0776
77371 Radiation treatment delivery, stereotactic radiosurgery (SRS)
complete course of treatment of cranial lesion(s) consisting of 1
session; multi -source Cobalt 60 based
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77372 Radiation treatment delivery, stereotactic radiosurgery (SRS)
complete course of treatment of cranial lesion(s) consisting of 1
session; linear accelerator based
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77373 Stereotactic body radiation therapy, treatment delivery, per
fraction to 1 or more lesions, including image guidance, entire
course not to exceed 5 fractions
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77385 Intensity modulated radiation treatment delivery (IMRT),
includes guidance and tracking when performed; simple 1/1/2019 AIM
Specialty Health AIM Provider Portal
866-666-0776
77386 Intensity modulated radiation treatment delivery (IMRT),
includes guidance and tracking when performed; complex 1/1/2019 AIM
Specialty Health AIM Provider Portal
866-666-0776
77387 Guidance for localization of target volume for delivery of
radiation treatment delivery, includes intrafraction tracking, when
performed
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77402 Radiation treatment delivery, up to 5 MeV; simple. All of the
following criteria are met (and none of the complex or intermediate
criteria are met): single treatment area, one or two B699ports and
two or fewer simple blocks
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77407 Radiation treatment delivery, up to 5 MeV; intermediate. Any
of the following criteria are met (and none of the complex criteria
are met): 2 separate treatment areas, 3 or more ports on a single
treatment area, or 3 or more simple blocks
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77412 Radiation treatment delivery, up to 5 MeV; complex. Any of
the following criteria are met: 3 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.
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77432 Stereotactic radiation treatment management of cranial
lesion(s) (complete course of treatment consisting of 1 session)
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77435 Stereotactic body radiation therapy, treatment management,
per treatment course, to 1 or more lesions, including image
guidance, entire course not to exceed 5 fractions
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
77470 Special treatment procedure (e.g., total body irradiation,
hemibody radiation, per oral or endocavitary irradiation) 1/1/2019
AIM Specialty Health AIM Provider Portal
866-666-0776
Page 48 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
77520 Proton beam delivery to a sgl treatment area, sgl port,
custom block 5/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
866-666-0776
77523 Proton beam delivery to one or two treatment areas, two or
more ports, two or more custom blocks 5/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
77525 Proton Treatment Delivery; Complex 5/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
866-666-0776
866-666-0776
866-666-0776
77767 Remote afterloading high dose rate radionuclide skin surface
brachytherapy, includes basic dosimetry, when performed; lesion
diameter up to 2.0 cm or 1 channel
5/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
5/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2019 AIM Specialty Health AIM Provider Portal
866-666-0776
Page 49 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78453 Myocardial 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)
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78454 Myocardial perfusion imaging, planar (including qualitative
or quantitative wall motion, ejection fraction by first pass or
gated technique, additional quantification, when B801performed);
multiple studies, at rest and/or stress (exercise or pharmacologic)
and/or redistribution and/or rest reinjection
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78459 PET myocardial, metabolic evaluation 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
78466 Planar, infarct avid; qualitative or quantitative 1/1/2018
AIM Specialty Health AIM Provider Portal
866-666-0776
78468 Planar, infarct avid; with ejection fraction by first pass
technique 1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78469 SPECT, infarct avid; with or without quantification 1/1/2018
AIM Specialty Health AIM Provider Portal
866-666-0776
78472 Gated equilibrium; planar, single study, wall motion plus
ejection fraction 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
78473 Gated equilibrium; planar, multiple studies, wall motion
study plus ejection fraction 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
78481 First pass technique; single study, wall motion study plus
ejection fraction 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
78483 First pass technique; multiple studies, wall motion study
plus ejection fraction 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
78491 PET myocardial perfusion, single study 1/1/2018 AIM Specialty
Health AIM Provider Portal
866-666-0776
Page 50 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
78492 PET myocardial perfusion, multiple studies 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
78494 Gated equilibrium: SPECT, at rest, wall motion study plus
ejection fraction 1/1/2018 AIM Specialty Health AIM Provider
Portal
866-666-0776
78608 PET brain, metabolic evaluation 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
78609 PET brain, perfusion evaluation 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
78811 PET imaging, limited area 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
78812 PET imaging, skull to mid-thigh 1/1/2018 AIM Specialty Health
AIM Provider Portal
866-666-0776
78813 PET imaging, whole body 1/1/2018 AIM Specialty Health AIM
Provider Portal
866-666-0776
78814 PET imaging, with concurrently acquired CT for attenuation
correction and anatomic localization; limited area 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
78815 PET imaging, with concurrently acquired CT for attenuation
correction and anatomic localization; skull base to mid- thigh
1/1/2018 AIM Specialty Health AIM Provider Portal
866-666-0776
78816 PET imaging, with concurrently acquired CT for attenuation
correction and anatomic localization; whole body 1/1/2018 AIM
Specialty Health AIM Provider Portal
866-666-0776
81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast
and ovaria n cancer) gene analysis; full sequence analysis and full
duplication/deletion analysis
5/1/2018 Premera Blue Cross
81200 Aspa (Aspartoacylase) (Eg, Canavan Disease) Gene Analysis,
Common Variants (Eg, E285A, Y2 31X) 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81201 APC (Adenomatous Polyposis Coli) Gene Analysis; Full Gene
Sequence 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 51 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
81202 APC (Adenomatous Polyposis Coli) Gene Analysis; Known
Familial Variants 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
81205 Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1, Beta
Polypeptide) Gene Analysis, Common Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81210 Braf (V-Raf Murine Sarcoma Viral Oncogene Homolog B1) (Eg,
Colon Cancer), Gene Analysis, V600E Variant 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81212 Brca1, Brca2 Gene Analysis; 185Delag, 5385Insc, 6174Delt
Variants 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81215 Brca1 (Breast Cancer 1) (Eg, Hereditary Breast And Ovarian
Cancer) Gene Analysis; Known Familial Variant 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81216 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian
Cancer) Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81217 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian
Cancer) Gene Analysis; Known Familial Variant 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81225 Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypepti de
19), Gene Analysis, Common Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81226 Cyp2D6 (Cytochrome P450, Family 2, Subfamily D, Polypeptide
6), Gene Analysis, Common Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81227 Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide
9), GeneAnalysis, Common Variants (Eg, -2, -3, -5, -6) 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 52 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Contact for Review:
81235 EGFR (epidermal growth factor receptor) (eg, non-small cell
lung cancer) gene analysis, common variants (eg, exon 19 LREA
deletion, L858R, T790M, G719A, G719S, L861Q)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
81243 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis;
Evaluation To Detect Abnormal (Eg, Expanded) Alleles 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
81244 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis;
Characterization Of Alleles 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
81255 Hexa (Hexosaminidase A [Alpha Polypeptide]) Gene Analysis,
Common Variants (Eg, 1278Instatc, 1421+1G>C, G269S) 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
81260 Inhibtr Of Kappa Light Plypeptide Gene Enhancr In B-Cells,
Kinase Complex-Assoc Protein Gene Analysis, Common Variants
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81275 Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg,
Carcinoma) Gene Analysis, Variants In Codons 12 And 13 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg,
carcinoma) gene analysis; additional variant(s) (eg, codon 61,
codon 146)
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81288 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg,
hereditary non -polyposis colorectal cancer, Lynch syndrome) gene
analysis; promoter methylation analysis
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 53 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
81290 Mcoln1 (Mucolipin 1) (Eg, Mucolipidosis, Type Iv) Gene
Analysis, Common Variants (Eg, Ivs3- 2A>G, Del6.4Kb) 5/1/2018
Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
81292 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene
Analys is; Full Sequence Analysis 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81293 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene
Analysis; Known Familial Variants 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81294 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene
Analysis; Duplication/Deletion Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81295 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene
Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81296 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene
Analysis; Known Familial Variants 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81297 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene
Analysis; Duplication/Deletion Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81298 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Full Sequence
Analysi s 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81299 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Known Familial
Variants 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81300 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis;
Duplication/Deletion Variants 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81302 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene
Analysis; Full Sequence Analysis 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81303 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene
Analysis; Known Familial Variant 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 54 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
81304 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene
Analysis; Duplication/Deletion Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81311 NRAS (neuroblastoma RAS viral [v ras] oncogene homolog) (eg,
colorectal carcinoma), gene analysis, variants in exon 2 (eg,
codons 12 and 13) and exon 3 (eg, codon 61)
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81317 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae])
Gene Analysis; Full Sequence Analysis 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81318 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae])
Gene Analysis; Known Familial Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81319 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae])
Gene Ana lysis; Duplication/Deletion Variants 5/1/2018 Premera Blue
Cross
Provider Portal 855-339-8127
81321 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Full
Sequence Analysis 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81322 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Known
Familial Variant 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
Provider Portal 855-339-8127
81325 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Full
Sequence Analysis 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Page 55 of 103 Premera Blue Cross Medicare Advantage Updated
02/11/2021
Code: Description: Effective
Contact for Review:
81326 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Known
Familial Variant 5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
Provider Portal 855-339-8127
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81332 Serpina1 (Serpin Peptidase Inhibitor, Clade A, Alpha -1
Antiproteinase, Antitrypsin, Member 1), Gene Analysis,Common
Variants
5/1/2018 Premera Blue Cross
5/1/2018 Premera Blue Cross
Provider Portal 855-339-8127
81355 Vkorc1 (Vitamin K Epoxide Re