clinical review preauthorization list - monroe plan
TRANSCRIPT
Rev 7/26/2013 1
A nonprofit independent licensee of the BlueCross BlueShield Association
Effective August 1, 2013
UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST
The following services require Clinical review preauthorization for commercial managed products, Medicare, Medicaid, Family Health Plus and Child Health Plus and certain PPO products. Please review the
column that applies to the member’s specific health benefit program regardless of place of service.
IMPORTANT
This list represents those services that require preauthorization with a Clinical Medical Necessity Review and is NOT inclusive of all insurance products and procedures requiring
preauthorization. There may be services which require Preauthorization / Notification that do not require Clinical review. Please verify specific coverage requirements before rendering service.
These services require preauthorization regardless of place of service.
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial Managed Care and Medicare
Products, Healthy Blue
PPO
Managed Safety
Net Products
Abdominoplasty and
Policy 7.01.53
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
Required Required
15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
Required Required
15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
Required Required
15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
Required Required
15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
Required Required
15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
Required Required
15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
Required Required
15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
Required Required
15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
Required Required
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., umbilical transportation and fascial plication) (list separately in addition to code for primary procedure)
Required Required
Rev 7/26/2013 2
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
15876 Suction assisted lipectomy; head and neck Required Required 15877 Suction assisted lipectomy; truck Required Required 15878 Suction assisted lipectomy; upper extremity Required Required 15879 Suction assisted lipectomy; lower extremity Required Required
Acoustic Cardiography Policy 2.01.43 0223T Acoustic cardiography, including automated
analysis of combined acoustic and electrical intervals; single, with interpretation and report
Required Required
0224T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter - AV or VV delays only, with interpretation and report
Required Required
0225T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter - AV and VV delays, with interpretation and report
Required Required
Adult Day Health Care (Medicaid ONLY)
THIS SERVICE IS ONLY COVERED FOR MANAGED MEDICAID effective 8/1/13
S5102 Day care services, adult; per diem NOT COVERED
Required
Revenue Code 3103 Adult day care, medical and social - daily NOT COVERED
Required
Air Ambulance (non- emergency only)
Policy 11.01.06
A0140 Non-emergency transportation and air travel (private or commercial) intra or inter state
Required Required
T2007 Transportation waiting time, air ambulance, and non-emergency vehicle, one-half (1/2) hour increments
Required Required
Airway Clearance Devices Policy 1.01.15 E0483 High frequency chest wall oscillation air-pulse
generator system (includes hoses and vest), each Required Required
Allograft for Spine Surgery InterQual 20931 Allograft for spine surgery only; structural (List
separately in addition to code for primary procedure)
Required Required
Ambulatory Traction D i
Policy 1.01.50
E0830 Ambulatory traction device. All types, each Required Required
Arthrodesis InterQual
Rev 7/26/2013 3
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description Commercial
Managed Care and Medicare
Products, Healthy Blue
Managed Safety Net Products
22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic
Required Required
22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar
Required Required
22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process
Required Required
22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
Required Required
22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (list in addition to code for separate procedure)
Required Required
22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
Required Required
22556 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic
Required Required
22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar
Required Required
22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
Required Required
22586 Arthrodesis, Pre-Sacral Interbody Technique, including disc space preparation, discectomy, with posterior instrumentation, with image- guidance, includes bone graft when performed; L5-S1 interspace
Required Required
22590 Arthrodesis, posterior technique, craniocervical (occiput-C2)
Required Required
22595 Arthrodesis, posterior technique, atlas-axis (C1- C2)
Required Required
22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
Required Required
22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique)
Required Required
Rev 7/26/2013 4
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description Commercial Managed Care and Medicare
Products, Healthy Blue
PPO
Managed Safety Net Products
22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)
Required Required
22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
Required Required
22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
Required Required
22634 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)
Required Required
0195T Arthrodesis, pre-sacral interbody technique, including instrumental, imaging (when performed) and discectomy to prepare interspace, lumbar; single interspace
Required Required
0196T Arthrodesis, pre-sacral interbody technique, including instrumental, imaging (when performed) and discectomy to prepare interspace, lumbar; each additional interspace (list separately in addition to code for primary procedure)
Required
Arthroplasty; Artificial Disc InterQual 22856 Total disc arthroscopy (artificial disc), anterior
approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection) single interspace, cervical
Required Required
22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar
Required Required
22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace, cervical
Required Required
22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace, lumbar
Required Required
22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
Required Required
22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar
Required Required
Rev 7/26/2013 5
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
0092T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), each additional interspace, cervical (list separately in addition to code for primary procedure)
Required Required
0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (list separately in addition to code for primary procedure)
Required Required
0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (list separately to code for primary procedure)
Required Required
0163T Total disc arthroplasty (artificial disc) anterior approach, including Discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (list separately in addition to code for primary procedure)
Required Required
0164T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (list separately in addition to code for primary procedure)
Required Required
0165T Revision including replacement of total disc arthroplasty (artificial disc) l anterior approach, each additional interspace, lumbar (list separately in addition to code for primary procedure)
Required Required
Autism Spectrum Services (ABA with diagnosis codes:
299.00, 299.10, or
Policy 3.01.11
H0032 Mental Health service plan by non-physician (consultation/supervision)
Required (Excludes Medicare
Advantage)
Required (Child Health Plus Only)
H2019 Therapeutic behavioral services, per 15 minutes
Required (Excludes Medicare
Advantage)
Required (Child Health Plus Only)
Autologous Chondrocyte Implantation
Policy 7.01.38
27412 Autologous chondrocyte implantation, knee Required Required
J7330 Autologous cultured chondrocytes, implant Required Required
S2112 Arthroscopy, knee, surgical for harvesting cartilage
Required Required
Rev 7/26/2013 6
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Autograft for Spine Surgery InterQual 20937 Autograft for spine surgery only (includes
harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
Required Required
20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
Required Required
Balloon Sinuplasty Policy 7.01.85
31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa
Required Required
31296 Nasal/Sinus endoscopy; surgical; with dilation of frontal sinus ostium (eg, balloon dilation)
Required Required
31297 Nasal/sinus endoscopy. Surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)
Required Required
C1726 Catheter, balloon dilation, nonvascular Required Required
Bariatric Procedures
(previously Gastric Bypass)
Policy 7.01.29
0312T Vagus nerve blocking therapy (Morbid Obesity) Laparoscopic implantation of Neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophogastric junction (EGJ) with implantation of pulse generator, includes [programming
Required Required
0313T Vagus nerve blocking therapy (Morbid Obesity). Laparoscopic revision or replacement of vagal trunk Neurostimulator electrode array, including connection to existing pulse generator
Required Required
0314T Vagus nerve blocking therapy (Morbid Obesity). Laparoscopic removal of vagal trunk Neurostimulator electrode array and pulse generator
Required Required
0315T Vagus nerve blocking therapy (Morbid Obesity). removal of pulse generator
Required Required
0316T Vagus nerve blocking therapy (Morbid Obesity). replacement of pulse generator
Required Required
Rev 7/26/2013 7
0317T Vagus nerve blocking therapy (Morbid Obesity). Neurostimulator Pulse Generator electronic analysis includes reprogramming when performed.
Required Required
43631 Gastrectomy, partial. Distal; with gastroduodenostomy
Required Required
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
Required Required
43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
Required Required
43659 Unlisted laparoscopy procedure, stomach Required Required
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components)
Required Required
43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
Required Required
43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
Required Required
43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
Required Required
43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
Required Required
43775 Laparoscopy, surgical Gastric restrictive procedure, Longitudinal Gastrectomy (i.e., Sleeve Gastrectomy)
Required Required
43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
Required Required
43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical- banded gastroplasty
Required Required
43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)
Required Required
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
Required Required
43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
Required Required
Rev 7/26/2013 8
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
Required Required
43886 Gastric restrictive procedure, open; revision of subcutaneous port component only
Required Required
43887 Gastric restrictive procedure, open; removal of subcutaneous port component only
Required Required
43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
Required Required
Biofeedback Policy 2.01.09
90901 Biofeedback training by any modality Required Required
90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
Required Required
E0746 Electromyography (EMG), biofeedback device Required Required
BiPAP Policy 1.01.06
E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
Required Required
E0471 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
Required Required
E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
Required Required
Blepharoplasty Policy 7.01.55
15820 Blepharoplasty, lower eyelid Required Required
15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad
Required Required
15822 Blepharoplasty, upper eyelid Required Required
15823 Blepharoplasty, upper eyelid; with extensive skin weighting down lid
Required Required
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
Required Required
Rev 7/26/2013 9
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia)
Required Required
67902 Repair of blepharoptosis frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
Required Required
67903 Repair of blepharoptosis; (taso) elevator resection or advancement, internal approach
Required Required
67904 Repair of blepharoptosis; (torso) elevator resection or advancement, external approach
Required Required
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
Required Required
67908 Repair of blepharoptosis; conjunctivo-tarso- Muller's muscle-elevator or resection (e.g., Fasanella-Servat type)
Required Required
67909 Reduction of overcorrection of ptosis Required Required 67999 Unlisted procedure, eyelids Required Required
Bone Growth Stimulation Policy 7.01.40 20974 Electrical stimulation to aid bone healing;
noninvasive (nonoperative) Required Required
20975 Electrical stimulation to aid bone healing; invasive (operative)
Required Required
20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
Required Required
E0747 Osteogenesis stimulator; electrical, non-invasive. Other than spinal application
Required Required
E0748 Osteogenesis stimulator; electrical, noninvasive, spinal applications
Required Required
E0749 Osteogenesis stimulator, electrical, surgically implanted
Required Required
E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive
Required Required
Breast Reconstruction, including Implant
Insertion, Removal or
Policy 10.01.01
11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micro pigmentation; 6.1 to 20.0 sq cm
Required Required
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
Required Required
19324 Mammaplasty, augmentation without prosthetic implant
Required Required
Rev 7/26/2013 10
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
19325 Mammaplasty, augmentation; with prosthetic implant
Required Required
19328 Removal of intact mammary implant Required Required
19330 Removal of mammary implant material Required Required
19340 Immediate insertion of breast prosthesis following mastoplexy, mastectomy or reconstruction
Required Required
19342 Delayed insertion of breast prosthesis following mastoplexy, mastectomy or in reconstruction
Required Required
19350 Nipple/areola reconstruction Required Required
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
Required Required
19366 Breast reconstruction with other technique Required Required 19370 Open periprosthetic capsulotomy, breast Required Required 19371 Periprosthetic capsulectomy, breast Required Required 19380 Revision of reconstructed breast Required Required
19396 Preparation of moulage for custom breast implant Required Required
Breast Reduction Surgery (includes Gynecomastia)
Policy 7.01.39
19300 Mastectomy for gynecomastia Required Required 19318 Reduction mammaplasty Required Required
Cardiovascular Telemetry Devices, Wearable; Mobile
Policy 2.01.03
93228 Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days: physician review and interpretation with report
Required Required
93229 Wearable mobile cardiovascular telemetry with electrocardiographic recording, technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports
Required Required
Chelation Therapy Policy 8.01.03 M0300 IV chelation therapy ; chemical endarterectomy Required Required
Rev 7/26/2013 11
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Clinical Trial* * For Medicare Advantage
Members, All codes below for Clinical Trails are not covered by the Health Plan as Primary Payer and should be billed to
Fee for Service Medicare. Cross over claims will be sent directly to the plan by CMS
Policy 11.01.10
Required Required
S9988 Services provided as part of a phase I clinical trial Required Required
S9990 Services provided as part of a phase II clinical trial Required Required
S9991 Services provided as part of a phase III clinical trial
Required Required
S9992 Transportation costs to and from trial location and local transportation costs (e.g., fares for taxicab or bus) for clinical trial participation and one caregiver/companion
Required Required
S9994 Lodging costs (e.g., hotel charges) for clinical trial participant and one caregiver/companion
Required Required
S9996 Meals for clinical trial participant and one caregiver/companion
Required Required
Cochlear Implant and Auditory Brain
Stem
Policy 7.01.26
69930 Cochlear device implantation, with or without mastoidectomy
Required Required
S2235 Implantation of auditory brain stem implant Required Required
Collagenase, Clostridium
Policy 5.01.15
J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg
Required Required
20527 Injection, enzyme (e.g. Collagenase), palmar fascial cord (i.e. Dupuytren’s contracture)
Required Required
26341 Manipulation, palmar fascial cord (i.e. Dupuytren’s cord) post enzyme injection (e.g. Collagenase), single cord
Required Required
Comfort and convenience Items
Policy 11.01.11
A4520 Incontinence garment, any type(e.g., brief, diaper), each
Required Required
A4554 Disposable underpads, all sizes Required Not Required
A9279 Monitoring feature/device, stand- alone or integrated, any type, includes all
Required Required
Rev 7/26/2013 12
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial Managed Care and Medicare Products,
Healthy Blue
Managed Safety
Net Products
A9280 Alarm or alert not otherwise specified Required Required
A9281 Reaching/grabbing device, any type, any length ,each
Required Requires
A9300 Exercise equipment Required Required
E0188 Synthetic sheepskin pad Required Not Required
E0210 Electric heat pad, standard Required N t R i d E0215 Electric heat pad, moist Required
Not Required
E0217 Water circulating heat pad with pump Required Required
E0240 Bath/shower chair, with or without wheels, any size
Required Required
E0241 Bath tub wall rail, each Required Required E0242 Bath tub rail, floor base Required Required
E0243 Toilet rail, each Required Required
E0245 Tub stool or bench Required Required E0274 Over-bed table Required Required
E0316 Safety enclosure frame/canopy for use with a hospital bed, any type
Required Required
E0625 Patient lift, bathroom or toilet, not otherwise classified
Required Required
E1300 Whirlpool; portable (overtub type) Required Required T4521 Adult sized disposable incontinence product,
brief/diaper, small, each Required Not Required
T4522 Adult sized disposable incontinence product, brief/diaper, medium, each
Required Not Required
T4523 Adult sized disposable incontinence product, brief/diaper, large, each
Required Not Required
T4524 Adult sized disposable incontinence product, brief/diaper, extra large, each
Required Not Required
T4525 Adult sized disposable incontinence product, protective underwear/pull-on, small size, each
Required Required
T4526 Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each
Required Required
T4527 Adult sized disposable incontinence product, protective underwear/pull-on, large size, each
Required Required
T4528 Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each
Required Required
T4529 Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each
Required Not Required
T4530 Pediatric sized disposable incontinence product, brief/diaper, large size, each
Required Not Required
Rev 7/26/2013 13
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial Managed Care and Medicare Products,
Healthy Blue
Managed Safety
Net Products
T4531 Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each
Required Required
T4532 Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each
Required Required
T4533 Youth sized disposable incontinence product, brief/diaper, each
Required Not Required
T4534 Youth sized disposable incontinence product, protective underwear/pull-on, each
Required Required
T4535 Disposable liner/shield/guard/pad/undergarment, for incontinence, each
Required Not Required
T4536 Incontinence product, protective underwear/pull- on, reusable, any size, each
Required Required
T4537 Incontinence product, protective underpad, reusable, bed size, each
Required Not Required
T4538 Diaper service, reusable diaper, each diaper Required Required
T4540 Incontinence product, protective underpad, reusable, chair size, each
Required Not Required
T4541 Incontinence product, disposable underpad, large, each
Required Required
T4542 Incontinence product, disposable underpad, small size, each
Required Required
T4543 Disposable incontinence product, brief/diaper, bariatric, each
Required Not Required
Continuous Glucose Monitoring Devices
Policy 1.01.30
A9276 Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply
Required Required
A9277 Transmitter; external, for use with interstitial continuous glucose monitoring system
Required Required
A9278 Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
Required Required
S1030 Continuous, noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)
Required Required
S1031 Continuous noninvasive glucose monitoring device rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)
Required Required
Cranial Orthotic Policy 1.01.32 S1040 Cranial remolding orthotic, pediatric, rigid, with
soft interface material, custom fabricated, includes fitting and adjustment (s).
Required Required
Rev 7/26/2013 14
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Day Treatment (Behavioral Health)
Policy 3.01.07
H2012 Behavioral health day treatment, per hour Required Required REV Code 907 Community Behavioral Health Program (Day
Treatment) Required Required
Decompression Procedure ( ) S i
Policy 7.01.62
62287 Decompression procedure, percutaneous, of nucleus pulposus of intervetebral disc, any method, single or multiple levels, lumbar (e.g., manual or automated percutaneous discectomy, percutaneous laser discectomy)
Required Required
S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervetebral disc, using radiofrequency energy, single or multiple levels, lumbar
Required Required
S9090 Vertebral axial decompression, per session
Deep Brain Stimulation Policy 7.01.23
61850 Twist drill or burr hole( s) for implantation of neurostimulator electrodes, cortical
Required Required
61863 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray) without use of intraoperative microelectrode recording; first array
Required Required
61864 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure code)
Required Required
61867 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray) with use of intraoperative microelectrode recording; first array
Required Required
Rev 7/26/2013 15
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
61868 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure code)
Required Required
61880 Revision or removal of intracranial neurostimulator electrodes
Required Required
61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
Required Required
61886 Insertion of replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
Required Required
61888 Revision or removal of cranial neurostimulator pulse generator or receiver
Required Required
L8680 Implantable neurostimulator electrode, each Required Required L8681 Patient programmer (external) for use with
implantable programmable neurostimulator pulse generator, replacement only
Required Required
L8682 Implantable neurostimulator radiofrequency receiver
Required Required
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
Required Required
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
Required Required
L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
Required Required
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
Required Required
L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
Required Required
L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only
Required Required
Dermabrasion Policy 7.01.11 15780 Dermabrasion; total face Required Required 15781 Dermabrasion; segmental, face Required Required 15782 Dermabrasion; regional, other than face Required Required 15783 Dermabrasion; superficial, any site (e.g., tattoo
removal) Required Required
Rev 7/26/2013 16
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Developmental Testing Policy 3.01.06
96111 Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report
Not Required Required
G0451 Developmental testing with interpretation and report, per standardized instrument form
Not Required Required
Discectomy including
InterQual
63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root (s), including osteophytectomy; cervical, single interspace
Required Required
63076 Discectomy, anterior, with decompression of spinal cord and/or nerve root (s), including osteophytectomy; cervical, single interspace cervical, each additional interspace (List separately in addition to code for primary procedure)
Required Required
63077 Discectomy, anterior, with decompression of spinal cord and/or nerve root (s), including osteophytectomy; thoracic, single interspace
Required Required
Experimental and Investigational
Procedures/ Services
Policy 11.01.03
0019T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy
Required Required
0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time
Required Required
0051T Implantation of total replacement heart system (artificial heart) with recipient cardiectomy
Required Required
0052T Replacement or repair of thoracic unit of a total replacement heart system
Required Required
0053T Replacement or repair of implantable component or components of a total replacement heart system (artificial heart), excluding thoracic unit
Required Required
0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image- guidance based on fluoroscopic images (list separately in addition to code for primary procedure)
Required Required
Rev 7/26/2013 17
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image- guidance based on CT/MRI images (list separately in addition to code for primary procedure)
Required Required
0071T Acoustic heart sound recording; interpretation and report only
Required Required
0072T Focused ultrasound ablation of uterine leiomyomata including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue
Required Required
0080T Endovascular repair of abdominal aortic aneurysm, pseudoaneurysm or dissection, abdominal aorta involving visceral vessels (superior mesenteric, celiac or renal), using fenestrated modular bifurcated prosthesis (2 docking limbs), radiological supervision and interpretation
Required Required
0081T Placement of visceral extension prosthesis for endovascular repair of abdominal aortic aneurysm involving visceral vessels, each visceral branch, radiological supervision and interpretation (list separately in addition to code for primary procedure)
Required Required
0084T Insertion of a temporary prostatic urethral stent Required Required 0085T Breath test for heart transplant rejection Required Required 0101T Extracorporeal shock wave involving
musculoskeletal system, not otherwise specified, high energy
Required Required
0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle
Required Required
0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation
Required Required
0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli
Required Required
0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia
Required Required
0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia
Required Required
0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to
Required Required
Rev 7/26/2013 18
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
0155T Laparoscopy, surgical; implantation or replacement of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity)
Required Required
0156T Laparoscopy, surgical; revision or removal of gastric stimulation electrodes, lesser curvature (i.e. morbid obesity)
Required Required
0157T Laparotomy, implantation or replacement of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity)
Required Required
0158T Laparotomy, revision or removal of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity)
Required Required
0159T Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (list separately in addition to code for primary procedure)
Required Required
0167T Transmyocardial transcather closure of ventricular septal defect, with implant, with cardiopulmonary bypass
Required Required
0174T Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitalization of film radiographic images, chest radiograph (s), performed concurrent with primary interpretation (list separately in addition to code for primary procedure)
Required Required
0175T Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph( s), performed remote from primary interpretation
Required Required
0178T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation and report
Required Required
0179T Electrocardiogram, 64 leads or greater, with tracing and graphics only, without interpretation and report
Required Required
0180T Electrocardiogram, 64 leads or greater, interpretation and report only
Required Required
0181T Corneal hysteresis determination, by air impulse stimulation, bilateral, with interpretation and report
Required Required
0182T High does rate electronic brachtherapy, per fraction
Required Required
0183T Low frequency, non-contact, non-thermal ultrasound. Including topical application( s) for ongoing care, per day
Required Required
Rev 7/26/2013 19
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
0185T Multivariate analysis of patient-specific findings with quantifiable computer probability assessment, including repot
Required Required
0186T Supsrachoroidal delivery of pharmacologic agent (does not include supply of medication)
Required Required
0188T Remote real-time interactive video-conference critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes
Required Required
0189T Remote real-time interactive video-conference critical care, evaluation and management of the critically ill or critically injured patient, each additional 30 minutes (list separately in addition to code for primary service)
Required Required
0190T Placement of intraocular radiation source applicator (list separately in addition to primary procedure
Required Required
0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach
Required Required
0192T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach
Required Required
0281T Percutaneous Transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement (s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation
Required Required
0282T Percutaneous or open implantation of Neurostimulator electrode array (s). subcutaneous (peripheral subcutaneous filed stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial including removal at the conclusion of
Required Required
0286T Near-Infrared spectroscopy studies of lower extremity wounds (e.g. for Oxyhemoglobin measurement)
Required Required
0287T Near-Infrared guidance for vascular access requiring real-time digital visualization of subcutaneous vasculature for evaluation of potential access sites and vessel patency
Required Required
0288T Anoscopy, with delivery of thermal energy to muscle of the anal canal (e.g. for rectal incontinence)
Required Required
19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma
Required Required
20985 Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-less (list separately in addition to code for primary procedure)
Required Required
Rev 7/26/2013 20
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
22505 Manipulation of spine requiring anesthesia, any region
Required Required
22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level
Required Required
22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels( list separately in addition to code for primary procedure)
Required Required
22586 Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed
Required Required
27446 Arthroplasty knee, condyle and plateau; medial OR lateral compartment
Required Required
28890 Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia
Required Required
29868 Arthroscopic knee, surgical meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral
Required Required
31647 Bronchoscopy, rigid or flexible including fluoroscopic guidance when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing and insertion of bronchial valve (s). Initial lobe
Required Required
31648 Bronchoscopy, rigid or flexible including fluoroscopic guidance when performed; with removal of bronchial valve (s). Initial lobe
Required Required
31649 Bronchoscopy, rigid or flexible including fluoroscopic guidance when performed; with removal of bronchial valve (s); each additional lobe (list separately in addition to code for primary procedure)
Required Required
31651 Bronchoscopy, rigid or flexible including fluoroscopic guidance when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing and insertion of bronchial valve (s). , each additional lobe (list separately in addition to code for primary procedure)
Required Required
31660 Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with bronchial Thermoplasty, 1 lobe
Required Required
31661 Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with bronchial Thermoplasty, 2 or more lobes
Required Required
Rev 7/26/2013 21
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
32998 Ablation therapy for reduction or eradication of one or more pulmonary tumor( s) including pleura or chest wall when involved by tumor extension,
Required Required
33255 Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); without cardiopulmonary bypass
Required Required
33258 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure( s), extensive (e.g., maze procedure), without cardiopulmonary bypass (list separately in addition to code for primary procedure)
Required Required
33265 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure), without cardiopulmonary bypass
Required Required
33266 Endoscopy surgical operative tissue ablation and reconstruction of atria, extensive (e.g. maze procedure), without cardiopulmonary bypass
Required Required
33542 Myocardial resection (e.g. ventricular aneurysmectomy)
Required Required
33548 Surgical ventricular restoration procedure, includes prosthetic patch, when performed (e.g., ventricular remodeling, SVR, SAVER, DOR procedures)
Required Required
41530 Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session
Required Required
43201 Esophagoscopy, rigid or flexible; diagnostic, with directed submucosal injection( s), any substance
Required Required
43257 Upper gastrointestinal endoscopy with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardiac, for treatment of gastroesophageal reflux disease
Required Required
44136 Intestinal allotransplantation; from living donor Required Required
44705 Preparation of Fecal Microbiota for instillation, including assessment of donor specimen
Required Required
46707 Repair of Anorectal Fistula with plug (e.g., Porcine small intestine submucosa (SIS) )
Required Required
47370 Laparoscopic, surgical, ablation of one or more liver tumor (s) ; radiofrequency
Required Required
47371 Laparoscopic, surgical, ablation of one or more liver tumor( s) ; cryosurgical
Required Required
47380 Ablation , open, of one or more liver tumor (s); radiofrequency
Required Required
47381 Ablation , open, of one or more liver tumor (s); cryosurgical
Required Required
Rev 7/26/2013 22
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
47382 Ablation, one or more liver tumor( s), percutaneous, radiofrequency
Required Required
50542 Laparoscopy, surgical; ablation of renal mass lesion (s)
Required Required
52855 Insertion of a temporary prostatic urethral stent, including urethral measurement
Required Required
61630 Balloon angioplasty, intracranial (e.g. atherosclerotic stenosis ) percutaneous
Required Required
61635 Transcatheter placement of intravascular stent (s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed
Required Required
61870 Craniectomy for implantation of neurostimulator electrodes, cerebellar, cortical
Required Required
62263 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
Required Required
62264 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day
Required Required
64553 Percutaneous implantation of neurostimulator electrodes, cranial nerve
Required Required
65770 Epikeratoplasty Required Required 74261 Computed tomographic (CT) colonography,
diagnostic, including image post processing; without contrast material
Required Required
74262 Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material (s) including non-contrast images, if preformed
Required Required
74263 Computes tomographic (CT) colongraphy (i.e., virtual colonoscopy); screening
Required Required
77082 Dual-energy X-ray vertebral fracture assessment Required Required
77605 Hyperthermia, externally generated; deep(i.e., heating to depths greater than 4cm)
Required Required
77610 hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators
Required Required
77615 hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators
Required Required
77620 Hyperthermia generated by intracavitary probe(s) Required Required
Rev 7/26/2013 23
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
81506 Endocrinology (Type 2 Diabetes), Biochemical Assays of Seven Analytes (Glucode, HBA1C, Insulin, HS-CRP, Adopncetin, Ferritin, Interleukin 2-receptoralpha), utilizing serum or plasma, algorithm reporting a risk score
Required Required
83698 Lipoprotein-associated phospholipase A2 (Lp- PLA2)
Required Required
83876 Myeloperoxidase (MPO) Required Required
83987 Exhaled breath condensate pH Required Required
84145 Procalcitonin (PCT) Required Required
86152 Cell enumeration using immunologic selection and identification in fluid specimen (eg. Circulation tumor cells in blood)
Required Required
86153 Cell enumeration using immunologic selection and identification in fluid specimen (eg. Circulating tumor cells in blood) physician interpretation and report when required.
Required Required
89251 Culture oocytes (s) /embryo( s), less than 4 days Required Required 87900 Infectious agent drug susceptibility phenotype
prediction using regularly updated genotypic bioinformatics
Required Required
89251 Culture of oocytes( s) /embryo (s), less than 4 days; with co-culture of oocyte (s) /embryo (s)
Required Required
89253 Assisted embryo hatching, microtechniques (any method)
Required Required
90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use
Required Required
90867 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment, initial, including cortical mapping, motor threshold determination, delivery and management.
Required Required
90868 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment, subsequent delivery and management, pre session
Required Required
90869 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment, subsequent motor threshold re-determination with delivery and management
Required Required
90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face to face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy); approximately 20-30 minutes
Required Required
Rev 7/26/2013 24
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
90876 Narcosynthesis for psychiatric diagnosis and therapeutic purposes(e.g., sodium amobarbital (Amytal) interview)
Required Required
91111 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with physician interpretation and report
Required Required
91112 Gastrointestinal transit and pressure measurement. Stomach through colon, wireless capsule, with interpretation and report
Required Required
92287 Special anterior segment photography with interpretation and report, with flourescein angiography
Required Required
93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias
Required Required
93982 Non invasive physiological study of implanted wireless pressure sensor in aneurismal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, interpretation and report
Required Required
94400 Breathing response to Co2 (Co2 response curve) Required Required 94452 High altitude simulation test (HAST), with
physician interpretation and report Required Required
94453 High altitude simulation test (HAST), with physician interpretation and report with supplemental oxygen titration
Required Required
95199 Unlisted allergy/clinical immunologic service or procedure
Required Required
95803 Actigraphy testing, recording, analysis, interpretation and report (minimum of 72 hours to 14 consecutive days of recording)
Required Required
96000 Comprehensive computer-based motion analysis by video-taping and 3D kinetics
Required Required
96001 Comprehensive computer-based motion analysis by video-taping and 3D kinetics, with dynamic plantar pressure measurements during walking
Required Required
96002 Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles
Required Required
96003 Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle
Required Required
96004 Physician review and interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities , and dynamic fine wire electromyography, with written report
Required Required
99174 Ocular photoscreening with interpretation and report
Required Required
A4575 Topical hyperbaric oxygen chamber, disposable Required Required
Rev 7/26/2013 25
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
C1818 Integrated keratoprosthesis Required Required C2614 Probe, percutaneous lumbar discectomy Required Required C9716 Creatins of thermal anal lesions by radiofrequency Required Required C9724 Endoscopic full-thickness plication in the gastric
cardia using endoscopic plication system (EPS); includes endoscopy
Required Required
C9727 Insertion of implants into the soft palate; minimum of three implants
Required Required
G0428 Collagen Meniscus Implant Required Required G0129 Occupational therapy services requiring the skills
of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)
Required Required
G0235 Pet imaging, any style, not otherwise specified Required Required G0252 PET imaging, full and partial-ring PET scanners
only for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)
Required Required
G0255 Current perception threshold/sensory nerve condition test, (SNCT) per limb, any nerve
Required Required
G0295 Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or other uses
Required Required
G0398 Home sleep study test (HST) with type II portable monitor , unattended; minimum of 7 channels; EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
Required Required
J3570 Laetrile, amygdalin, vitamin B17 Required Required L8609 Artificial cornea Required Required
M0075 Cellular therapy Required Required
S2300 Arthroscopy, shoulder, surgical; with thermally- induced capsulorrhaphy
Required Required
S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervetebral disc, using radiofrequency energy, single or multiple levels, lumbar
Required Required
S3852 DNA analysis for APOE epsilon 4 allele for susceptibly to Alzheimer's disease
Required Required
S3855 Genetic testing for detection of mutation in the presenilin, 1 gene
Required Required
S3890 DNA analysis, fecal, for colorectal cancer screening
Required Required
S3900 Surface electromyography (EMG) Required Required
Rev 7/26/2013 26
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
S3905 Non-invasive electrodiagnostic testing with automatic computerized hand-held device to stimulate and measure neuromuscular signals in diagnosing and evaluating systemic and entrapment of neuropathies
Required Required
S8040 Topographic brain mapping Required Required S8080 Scintimammography (raidoimmunoscintigraphy of
the breast), unilateral, including supply of radiopharmaceutical
Required Required
S9025 Omnicardiogram/cardiointegram Required Required S9055 Procuren or other growth factor preparation to
promote wound healing Required Required
S9090 Vertebral axial decompression, per session Required Required S9991 Services provided as part of a phase III clinical
trial Required Required
Functional Neuromuscular
Policy 1.01.48
E0764 Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program
Required Required
E0765 FDA approved nerve stimulator with replaceable batteries for treatment of nausea and vomiting
Required Required
Gait Trainer Policy 1.01.46 E8000 Gait Trainer, pediatric size, posterior support,
includes all accessories and components Required Required
E8001 Gait Trainer, pediatric size, upright support, includes all accessories and components
Required Required
E8002 Gait Trainer, pediatric size, anterior support, includes all accessories and components
Required Required
Gastric Electrical Stimulation
Policy 7.01.64
43647 Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum
Required Required
43648 Laparoscopy revision or removal of gastric neurostimulator electrodes, antrum
Required Required
43881 Implantation or replacement of gastric neurostimulator electrodes, antrum, open
Required Required
43882 Revision or removal of gastric neurostimulator electrodes, antrum, open
Required Required
Rev 7/26/2013 27
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
95980 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, batter status, electrode selectability, output modulation, cycling, impedance and patient measurement) gastric neurostimulator pulse generator/transmitter; intraoperative, with programming
Required Required
95981 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, batter status, electrode selectability, output modulation, cycling, impedance and patient measurement) gastric neurostimulator pulse generator/transmitter; subsequent, without reprogramming
Required Required
95982 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, batter status, electrode selectability, output modulation, cycling, impedance and patient measurement) gastric neurostimulator pulse generator/transmitter; subsequent, with reprogramming
Required Required
Genetic Testing Multiple Policies. See policy list for specific testing
81200 ASPA (aspartoacylase) (e.g., canavan disease) gene analysis, common variants (e.g., e285a, y231x)
Required Required
81201 APC (Adenomatous Polyposis Coli) (eg. Familial Adenomatosis Polyposis (FAP) Attenuated FAP) Gene Analysis, Full gene sequence
Required Required
81202 APC (Adenomatous Polyposis Coli) (eg. Familial Adenomatosis Polyposis (FAP) Attenuated FAP) Gene Analysis, known familial variants
Required Required
81203 APC (Adenomatous Polyposis Coli) (eg. Familial Adenomatosis Polyposis (FAP) Attenuated FAP) Gene Analysis, Duplication/Deletion variants
Required Required
81205 BCKDHB (branched-chain keto acid dehydrogenase e1, beta polypeptide) (e.g., maple syrup urine disease) gene analysis, common variants (e.g., r183p, g278s, e422x
Required Required
81209 BLM (Bloom syndrome, RECQ Helicase-like) (e.g., Bloom syndrome) gene analysis, 2281del6ins7 variant
Required Required
81210 BRAF (V-RAF Murine sarcoma viral oncogene homolog b1) (e.g., colon cancer), gene analysis, v600e variant
Required Required
Rev 7/26/2013 28
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
81211 BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)
Required Required
81212 BRCA1, BRCA2 (BREAST CANCER 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; 185delag, 5385insc, 6174delt variants
Required Required
81213 BRCA1, BRCA2 (BREAST CANCER 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants
Required Required
81214 BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)
Required Required
81215 BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant
Required Required
81216 BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis
Required Required
81217 BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant
Required Required
81227 CYP2C9 (Cytochrome P450, family 2, subfamily c, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6)
Required Required
81228 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., bacterial artificial chromosome [bac] or oligo-based comparative genomic hybridization [cgh] microarray analysis)
Required Required
81229 CYTOGENOMIC constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (snp) variants for chromosomal abnormalities
Required Required
Rev 7/26/2013 29
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
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)
Required Required
81240 F2 (Prothrombin, Coagulation Factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210g>a variant
Required Required
81241 F5 (Coagulation Factor V) (e.g., hereditary hypercoagulability) gene analysis, leiden variant
Required Required
81242 FANCC (Fanconi Anemia, Complementation Group C) (e.g., fanconi anemia, type c) gene analysis, common variant (e.g., ivs4+4a>t)
Required Required
81243 FMR1 (Fragile X Mental Retardation 1) (e.g., fragile x mental retardation) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles
Required Required
81244 FMR1 (Fragile X Mental Retardation 1) (e.g., Fragile X Mental retardation) gene analysis; characterization of alleles (e.g., expanded size and methylation status)
Required Required
81250 G6PC (Glucose-6-Phosphatase, Catalytic Subunit) (e.g., glycogen storage disease, type 1a, von gierke disease) gene analysis, common variants (e.g., r83c, q347x)
Required Required
81251 GBA (Glucosidase, Beta, Acid) (e.g., Gaucher Disease) gene analysis, common variants (e.g., n370s, 84gg, l444p, ivs2+1g>a)
Required Required
81252 GJB2 (Gap Junction protein, BETA 6, 26DA Connexin 26) eg. Nonsyndromic hearing loss) gene analysis, full gene sequence
Required Required
81253 GJB2 (Gap Junction protein, BETA 6, 26DA Connexin 26) eg. Nonsyndromic hearing loss) gene analysis, known familial variants
Required Required
81254 GJB6 (Gap Junction protein, BETA 6, 30DA Connexin 30) eg. Nonsyndromic hearing loss) gene analysis, common variants (eg. 309KB [DEL(GJB6-D13S))] and 232KB [DEL (GJB6- D13S1854)])
Required Required
81255 HEXA (Hexosaminidase A [Alpha Polypeptide]) (e.g., Tay-Sachs disease) gene analysis, common variants (e.g., 1278instatc, 1421+1g>c, g269s
Required Required
81256 HFE (Hemochromatosis) (e.g., Hereditary hemochromatosis) gene analysis, common variants (e.g., c282y, h63d)
Required Required
Rev 7/26/2013 30
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
81257 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring)
Required Required
81260 IKBKAP (inhibitor of Kappa light polypeptide gene enhancer in B-cells, kinase complex- associated protein) (e.g., familial Dysautonomia) gene analysis, common variants (e.g., 2507+6t>c, r696p)
Required Required
81280 Long QT Syndrome gene analyses (eg,KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4b, AKAP, SNTA1, and ANK2); full sequence analysis
Required Required
81281 Long QT syndrome gene analyses (e.g., KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); known familial sequence variant
Required Required
81282 Long QT syndrome gene analyses (e.g., KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACCA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); duplication/deletion variants
Required Required
81290 MCOLN1 (Mucolipin 1) (eg,Mucolipidosis, type IV) gene analysis, common variants (e.g., IVS3- 2A>G, DEL6.4KB)
Required Required
81291 MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C)
Required Required
81292 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis
Required Required
81293 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants
Required Required
81294 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants
Required Required
81295 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis
Required Required
81296 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants
Required Required
Rev 7/26/2013 31
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
81297 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants
Required Required
81298 MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis
Required Required
81299 MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants
Required Required
81300 MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants
Required Required
81301 Microsatellite instability analysis (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (e.g., BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed
Required Required
81302 MECP2 (methyl CPG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis
Required Required
81303 MECP2 (methyl CPG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant
Required Required
81304 MECP2 (methyl CPG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants
Required Required
81317 PMS2 (postmeiotic segregation increased 2 [s. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis
Required Required
81318 PMS2 (postmeiotic segregation increased 2 [s. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis
Required Required
81319 PMS2 (postmeiotic segregation increased 2 [s. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants
Required Required
81321 PTEN (Phosphate and Tensin Homolog ) (eg. Cowden Syndrome PTEN Hamartoma Tumor Syndrome) Gene analysis, full sequence analysis
Required Required
81322 PTEN (Phosphate and Tensin Homolog ) (eg. Cowden Syndrome PTEN Hamartoma Tumor Syndrome) Gene analysis, known familial variant
Required Required
Rev 7/26/2013 32
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
81323 PTEN (Phosphate and Tensin Homolog ) (eg. Cowden Syndrome PTEN Hamartoma Tumor Syndrome) Gene analysis, Duplication/Deletion variant
Required Required
81324 PM22 (Peripheral Myelin Protein 22) (eg. Charcot-Marie-Tooth, Hereditary Neuropathy with liability to pressure palsies) Gene analysis; Duplication/Deletion analysis
Required Required
81325 PM22 (Peripheral Myelin Protein 22) (eg. Charcot-Marie-Tooth, Hereditary Neuropathy with liability to pressure palsies) Gene analysis; full sequence analysis
Required Required
81326 PM22 (Peripheral Myelin Protein 22) (eg. Charcot-Marie-Tooth, Hereditary Neuropathy with liability to pressure palsies) Gene analysis; known familial variant
Required Required
81330 SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (e.g., Niemann-Pick disease, type a) gene analysis, common variants (e.g., r496l, l302p, fsp330)
Required Required
81331 SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
Required Required
81332 SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (e.g., alpha-1-antitrypsin deficiency), gene analysis, common variants (e.g., *s and *z)
Required Required
81350 UGT1A1(UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37)
Required Required
81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (e.g., warfarin metabolism), gene analysis, common variants (e.g., -1639/3673)
Required Required
S3800 Genetic testing for amyotrophic lateral sclerosis (ALS)
Required Required
S3818 Complete gene sequence analysis; BRCA1 gene Required Required
S3819 Complete gene sequence analysis; BRCA2 gene Required Required
S3820 Complete BRCA1 and BRCA2 gene sequence analysis for susceptibility to breast and ovarian cancer
Required Required
Rev 7/26/2013 33
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
S3821 Three mutation BRCA 1 and BRCA 2 analysis for susceptibility to breast and ovarian cancer in Ashkenazi individuals
Required Required
S3822 Single mutation analysis (in individual with a knownBRCA1 or BRCA2 mutation in the family) for susceptibility to breast and ovarian cancer
Required Required
S3823 Three-mutation BRCA1 and BRCA2 analysis for susceptibility to breast and ovarian cancer on Ashkenazi individuals
Required Required
S3828 Complete gene sequence analysis; MLH1 gene Required Required
S3830 Complete mlhl1and mlh2 gene sequence analysis for hereditary nonpolyposis colorectal cancer (HNPCC) genetic testing
Required Required
S3831 Single-mutation analysis (in individual with a known mhl1 and mlh2 mutation in the family) for hereditary nonpolyposis colorectal cancer (HNPCC) genetic testing
Required Required
S3833 Complete APC gene sequence analysis for susceptibility to familial adenomatous polyposis (FAP) and attenuated FAP
Required Required
S3834 Single-mutation analysis ( in individuals with a known APC mutation in the family) for susceptibility to familial adenomatous polyposis (FAP and attenuated FAP
Required Required
S3837 Complete gene sequence analysis for hemochromatosis genetic testing
Required Required
S3841 Genetic testing for retinoblastoma Required Required
S3842 Genetic testing for von Hippel-Lindau disease Required Required
S3843 DNA analysis of the F5 gene for susceptibility to Factor V Leiden thrombophilia
Required Required
S3844 DNA analysis of the connexin 26 gene (GJB2) for susceptibility to congenital, profound deafness
Required Required
S3845 Genetic testing for alpha-thalassemia Required Required
S3846 Genetic testing for hemoglobin E beta- thalassemia
Required Required
S3847 Genetic testing for Tay-Sachs disease Required Required
S3848 Genetic testing for Gaucher disease Required Required
Rev 7/26/2013 34
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
S3849 Genetic testing for Niemann-Pick disease Required Required
S3850 Genetic testing for Sickle cell anemia Required Required
S3851 Genetic testing for Canavan disease Required Required
S3852 DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease
Required Required
S3853 Genetic testing for myotonic muscular dystrophy Required Required S3854 Gene expression profiling panel for use in the
management of breast cancer treatment Required Required
S3855 Genetic testing for detection of mutations in the presenilin, 1 gene
Required Required
S3860 Genetic testing, comprehensive cardiac ion channel analysis, for variants in 5 major cardiac ion channel genes for individuals with high index of suspicion for familial long qt syndrome (lqts) or relaxed syndromes
Required Required
S3861 Genetic testing, sodium channel, voltage-gates, type V, alpha subunit (scn5a) and variants for suspected Brugada syndrome
Required Required
S3862 Genetic testing, family-specific ion channel analysis, for blood-relatives of individuals (index case) who have previously tested positive for genetic variant of a cardiac ion channel syndrome using wither one of the above test configurations or confirmed results for another laboratory
Required Required
S3890 DNA Analysis, fecal, for colorectal cancer screening
Required Required
Group Therapy Policy 3.01.08
90853 Group Psychotherapy (other than of a multiple-family group)
Required Required
REV Code 915 Psychiatric/Psychological Services - Group Therapy
Required Required
Hearing Aids (Safety net Only)
V5030 Hearing aid, monaural, body worn, air conduction Not Required Required
V5040 Hearing aid, monaural, body worn, bone conduction
Not Required Required
V5050 Hearing aid, monaural, in the ear Not Required Required V5060 Hearing aid, monaural, behind the ear Not Required Required V5070 Glasses, air conduction Not Required Required V5080 Glasses, bone conduction Not Required Required
Rev 7/26/2013 35
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
V5120 Binaural, body Not Required Required
V5130 Binaural, in the ear Not Required Required V5140 Binaural, behind the ear Not Required Required
V5150 Binaural, glasses Not Required Required
V5170 Hearing aid, CROS, in the ear Not Required Required V5180 Hearing aid, CROS, behind the ear Not Required Required V5190 Hearing aid, CROS, glasses Not Required Required V5200 Dispensing fee, CROS Not Required Required V5210 Hearing aid BICROS, in the ear Not Required Required V5220 Hearing aid, BICROS, behind the ear Not Required Required V5230 Hearing aid, BICROS, glasses Not Required Required
V5240 Dispensing fee, BICROS Not Required Required V5246 Hearing aid, digitally programmable analog,
monaural, ITE (in the ear) Not Required Required
V5247 Hearing aid, digitally programmable analog, monaural, BTE (behind the ear)
Not Required Required
V5252 Hearing aid, digitally programmable, binaural, ITE Not Required Required
V5253 Hearing aid, digitally programmable, binaural, BTE
Not Required Required
V5256 Hearing aid, digital, monaural, ITE Not Required Required
V5257 Hearing aid, digital, monaural, BTE Not Required Required V5260 Hearing aid, digital, binaural, ITE Not Required Required
V5261 Hearing aid, digital, binaural, ITE Not Required Required L8619 Cochlear implant, external speech processor and
controller, integrated system, replacement Not Required Required
L8692 Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband, or other means of external; attachment
Not Required Required
Hip Replacement including total and
InterQual
20985 Computer- assisted surgical navigational procedure for musculoskeletal procedures, image- less (list separately in addition to code for primary procedure)
Required Required
27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
Required Required
27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft
Required Required
Rev 7/26/2013 36
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral components
Required Required
Home Care InterQual 99601 Home infusion/specialty drug administration, per
visit (up to 2 hours); Required Required
99602 Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List
Required Required
S9097 Home visit for wound care Required Required
S9098 Home visit, phototherapy services (e.g., Bili-lite), including equipment rental, nursing services, blood draw, supplies and other services, per diem
Required Required
S9122 Home health aide or certified nurse assistant, providing care in the home; per hour
Required Required
S9123 Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not
Required Required
S9124 Nursing care, in the home by licensed practical nurse, per hour
Required Required
S9125 Respite care in the home, per diem Required Required
S9127 Social work visit, in the home, per diem Required Required
S9128 Speech therapy, in the home, per diem Required Required S9129 Occupational therapy, in the home, per diem Required Required
S9131 Physical therapy, in the home, per diem Required Required T1000 Private duty/independent nursing service (s),
licensed, up to 15, minutes Required Required
T1001 Nursing assessment/evaluation Required Required
T1002 RN services, up to 15 minutes Required Required
T1003 LPN/LVN services, up to 15 minutes Required Required
T1004 Services of a qualified nursing aide, up to 15 minutes
Required Required
T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility,
Not Covered Required
T1020 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
Not Covered Required
Rev 7/26/2013 37
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
T1021 Home health aide or certified nurse assistant, per visit
Required Required
T1030 Nursing care, in the home, by registered nurse, per diem
Required Required
T1031 Nursing care, in the home, by licensed practical nurse, per diem
Required Required
Homecare Tele-Health Policy 1.01.49 Q3014 Telehealth originating site facility fee Not Covered Required
(excludes CHP and FHP)
S9109 Congestive heart failure telemonitoring, equipment rental, including telescale, computer system and software, telephone connections, and maintenance, per month
Not Covered Required (excludes CHP
and FHP)
Home Uterine Monitoring Policy 1.01.13 S9001 Home uterine monitor with or without associated
nursing services Required Required
Hospital and Air Fluidized
InterQual
E0194 Air Fluidized Bed Required Required E0255 Hospital bed, variable height, hi-lo, with any type
side rails; with mattress Required Required
E0260 Hospital bed, semi-electric (head and foot adjustment) with any type side rails; with mattress
Required Required
E0261 Hospital bed, semi-electric (head and foot adjustment) with any type side rails; without mattress
Required Required
E0265 Hospital bed, total electric (head, foot and height adjustments), with any type side rails; with mattress
Required Required
E0266 Hospital bed, total electric (head, foot and height adjustments), with any type side rails; without mattress
Required Required
E0290 Hospital bed; fixed-height, without side rails; with mattress
Required Required
E0292 Hospital bed; fixed-height, without side rails; with mattress
Required Required
E0294 hospital bed, semi-electric (head and foot adjustment) without side rails; with mattress
Required Required
E0295 Hospital bed, semi-electric (head and foot adjustment) without side rails; without mattress
Required Required
E0296 Hospital bed, total electric (head, foot and height adjustments) without side rails; with mattress
Required Required
E0297 Hospital bed, total electric (head, foot and height adjustments) without side rails; without mattress
Required Required
E0301 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress
Required Required
Rev 7/26/2013 38
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any
Required Required
E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with
Required Required
E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress
Required Required
E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress
Required Required
E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress
Required Required
Hospital to Hospital Transfer
Policy 11.01.18 Required Required
Hyperbaric Oxygen Therapy
Policy 2.01.07
99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session
Required Required
A4575 Topical hyperbaric oxygen chamber, disposable Required Required
C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
Required Required
E0446 Topical Oxygen Delivery system, Not Otherwise Specified, includes all supplies and accessories
Required Required
Hyperhydrosis Surgery Policy 7.01.11
32664 Thoracoscopy, surgical; with thoracic sympathectomy
Required Required
64821 Sympathectomy; radial artery Required Required
64822 Sympathectomy; ulnar artery Required Required 64823 Sympathectomy; superficial palmar arch Required Required
Inpatient Hospital Admissions
Inpatient Admissions (except routine Maternity) to any facility including hospital, elective and direct admit, acute rehab, SNF, behavioral health substance abuse and hospital to hospital transfers. Emergency Admissions require notification to the Health Plan
Required Required
Rev 7/26/2013 39
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Insulin Pump Policy 10.01.04
E0784 External ambulatory infusion pump, insulin Required Required Intensive Outpatient
Behavioral Health Treatment
Policy 3.01.07
S9480 Intensive outpatient psychiatric services, per diem Required Required REV Code 905 Intensive outpatient psychiatric services Required Required
Intensity-Modulated Radiation
Policy 6.01.24
77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
Required Required
77338 Multi-leaf Collimator (MLC) Device (s) for IMRT design and construction per IMRT Plan
Required Required
77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session
Required Required
0073T Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session
Required Required
Intrapulmonary Percussive Device
Policy 1.01.15
E0481 Intrapulmonary percussive ventilation system and related accessories
Required Required
Knee Braces, Custom only InterQual
L1834 Knee orthotic (KO) without knee joint, rigid, custom fabricated
Required Required
L1840 Knee orthotic, derotation, medial-lateral, anterior cruciate ligament, custom fabricated
Required Required
L1844 Knee orthotic, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric) medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
Required Required
L1846 Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
Required Required
Rev 07/26/2013 40
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Knee Replacement including
Unicondylar (previously
InterQual
20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image- less (List separately in addition to code for primary procedure)
Required Required
27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
Required Required
27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
Required Required
Kyphoplasty Policy 6.01.17
22523 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); thoracic
Required Required
22524 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); lumbar
Required Required
Laminectomy InterQual
63001 Laminectomy with exploration and/or decompression of spinal cord and/or caudal equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; cervical
Required Required
63003 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; thoracic
Required Required
63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis
Required Required
63012 Laminectomy with removal of abnormal facets and/or pars inter-articulars with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)
Required Required
63015 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; cervical
Required Required
Rev 07/26/2013 41
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
63016 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; thoracic
Required Required
63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; lumbar
Required Required
63046 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic
Required Required
63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
Required Required
63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;
Required Required
63055 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervetebral disc), single segment; thoracic
Required Required
63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(S) (e.g. herniated intervertebral disc) single segment, lumbar (including transfacet or lateral extraforaminal approach) (e.g., far lateral herniated intervertebral disc)
Required Required
63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(S) (e.g. herniated intervertebral disc); each additional segment, thoracic or lumbar (list separately in addition to code for primary procedure)
Required Required
63064 Costovertebral approach with decompression of spinal cord or nerve root(s) (e.g., herniated intervertebral disc), thoracic; single segment
Required Required
Laminotomy/Laminectomy; Percutaneous
InterQual
0274T Percutaneous Laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic
Required Required
Rev 07/26/2013 42
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
0275T Percutaneous Laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral lumbar
Required Required
LVAD Policy 7.01.07
33975 Insertion of ventricular assist device; extracorporeal, single ventricle
Required Required
33976 Insertion of ventricular assist device; extracorporeal, biventricular
Required Required
33977 Removal of ventricular assist device; extracorporeal, single ventricle
Required Required
33978 Removal of ventricular assist device; extracorporeal, biventricular
Required Required
33979 Insertion of ventricular assist device, implantable intracorporeal, single ventricle
Required Required
33980 Removal of ventricular assist device, implantable intracorporeal, single ventricle
Required Required
33990 Insertion of Ventricular Assist Device, percutaneous including radiological supervision and interpretation, BOTH arterial and venous access, with transseptal puncture
Required Required
33991 Implantation of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation
Required Required
33992 Removal of percutaneous ventricular assist device at separate and distinct session from insertion
Required Required
33993 Repositioning of percutaneous ventricular assist device with image guidance at separate and distinct session from insertion
Required Required
Q0480 Driver for use with pneumatic ventricular assist device, replacement only
Required Required
Q0481 Microprocessor control unit for use with electric ventricular assist device, replacement only
Required Required
Q0482 Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only
Required Required
Q0483 Monitor/display module for use with electric ventricular assist device, replacement only
Required Required
Q0484 Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0485 Monitor control cable for use with electric ventricular assist device, replacement only
Required Required
Rev 07/26/2013 43
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Q0486 Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only
Required Required
Q0487 Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only
Required Required
Q0488 Power pack base for use with electric ventricular assist device, replacement only
Required Required
Q0489 Power pack base for use with electric/pneumatic ventricular assist device, replacement only
Required Required
Q0490 Emergency power source for use with electric ventricular assist device, replacement only
Required Required
Q0491 Emergency power source for use with electric/pneumatic ventricular assist device, replacement only
Required Required
Q0492 Emergency power supply cable for use with electric ventricular assist device, replacement only
Required Required
Q0493 Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only
Required Required
Q0494 Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0495 Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0496 battery for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0497 Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0498 Holster for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0499 Belt/vest for use with electric or electric pneumatic ventricular assist device, replacement only
Required Required
Q0500 Filters for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0501 Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only
Required Required
Q0502 Mobility cart for pneumatic ventricular assist device, replacement only
Required Required
Q0503 Battery for pneumatic ventricular assist device, replacement only, each
Required Required
Q0504 Power adapter for pneumatic ventricular assist device, replacement only, vehicle type
Required Required
Rev 07/26/2013 44
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Q0507 Miscellaneous supply or accessory for use with an external Ventricular Assist Device
Required Required
Q0508 Miscellaneous supply or accessory for use with an implanted Ventricular Assist Device
Required Required
Q0509 Miscellaneous supply or accessory for use with any implanted Ventricular assist Device for which payment was not made under Medicare Part A
Required Required
Miscellaneous and Unlisted codes
A0999 Unlisted ambulance service Required
Required
A6512 Compression burn garment, not otherwise classified
Required
Required
A6549 Gradient compression stocking, not otherwise specified
Required
Required
A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code
Required
Required
A9999 Miscellaneous DME supply or accessory, not otherwise specified
Required
Not Required
B9998 NOC for enteral supplies Required
Not Required B9999 NOC for parenteral supplies
Required
Not Required E1399 Durable medical equipment, miscellaneous
Required
Required K0898 Power wheelchair, not otherwise classified Required
Required
K0899 Power mobility device, not coded by DME PDAC or does not meet criteria
Required
Required
L1499 Spinal orthotic, not otherwise specified Required
Required
L2999 Lower extremity orthotic, not otherwise specified Required
Required
L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified
Required
Required
L3999 upper limb orthotic, not otherwise specified Required
Required
L8499 Unlisted procedure for miscellaneous prosthetic services
Required
Required
T1999 Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified. Identify product in "remarks"
Required
Required
T5999 Supply, not otherwise specified Required Not Required
Rev 07/26/2013 45
Clinical Review Preauthorization
Requirements and Corresponding Procedure
Codes
Description
Commercial
Managed Care and Medicare
Products, Healthy Blue
Managed Safety Net Products
Neuromuscular Stimulation for Scoliosis
and electrical
Policy 1.01.48
0282T Percutaneous or open implantation of Neurostimulator electrode array (s), subcutaneous (peripheral subcutaneous filed stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial including removal.
Required Required
0283T Percutaneous or open implantation of Neurostimulator electrode array (s), subcutaneous (peripheral subcutaneous filed stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator.
Required Required
0284T Revision or removal of pulse generator or electrodes including image guidance, when performed, including addition of new electrodes when performed.
Required Required
0285T Electrical analysis of implanted peripheral subcutaneous liked stimulation pulse generator, with reprogramming when performed
Required Required
E0744 Neuromuscular stimulator for scoliosis Required Required E0745 Neuromuscular stimulator, electronic shock unit Required Required
Neuropsychological Testing
Policy 3.01.01
96118 Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
Required
Required
96119 Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
Required
Required
96120 Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report
Required
Required
Occupational Therapy Policy 8.01.17
97004 Occupational therapy re-evaluation Required Required
97535 Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology
Required Required
Rev 07/26/2013 46
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
97537 Community/work reintegration training (e.g., shopping, transportation, money management, a vocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes
Required Required
97545 Work hardening/conditioning; initial 2 hours Required Required
97546 Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure)
Required Required
G0129 Occupational therapy services requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment
Required Required
G9041 Rehabilitative services for low vision by qualified occupational therapist, direct one-on-one contact, each 15 minutes
Required Required
G9042 Rehabilitative services for low vision by certified orientation and mobility specialists, direct one-on- one contact, each 15 minutes
Required Required
G9043 Rehabilitative services for low vision by certified low vision rehabilitative therapist, direct one-on- one contact, each 15 minutes
Required Required
G9044 Rehabilitative services for low vision by certified low vision rehabilitation teacher, direct one-on-one contact, each 15 minutes
Required Required
Osteochondral Bone Graft Policy 7.01.59
28446 Open osteochondral autograft, talus (includes obtaining graft[s])
Required Required
Otoplasty
Policy 7.01.11
69300 Otoplasty, protruding ear, with or without size reduction
Required Required
Orthopedic / Orthotic Devices Per
Product Requirements
See Custom Knee Braces, and Cranial orthotics. Please verify member contract requirements for additional preauthorization requirements
Palatopharyngoplasty Uvulopalatopharyngoplasty
Policy 7.01.41
42145 Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty)
Required Required
Rev 07/26/2013 47
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
S2080 Laser-assisted uvulopalatoplasty (laup) Required Required Partial hospitalization
(Behavioral health) InterQual
H0035 mental health partial hospitalization, treatment, less than 24 hours
Required Required
S0201 Partial hospitalization services, less than 24 hours, per diem
Required Required
REV Code 912 Psychiatric/Psychological Services - Partial Hosp. Less Intensive
Required Required
REV Code 913 Psychiatric/Psychological Services - Partial Hosp. Intensive
Required Required
Personal Care Services Please see Homecare
See Homecare Not Covered Required Physical Therapy Policy 8.01.12
97002 Physical therapy re-evaluation Required Required
97010 Application of a modality to 1 or more areas; hot or cold packs
Required Required
97012 Application of a modality to 1 or more areas; traction, mechanical
Required Required
97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
Required Required
97016 Application of a modality to 1 or more areas; vasopneumatic devices
Required Required
97018 Application of a modality to 1 or more areas; paraffin bath
Required Required
97022 Application of a modality to 1 or more areas; whirlpool
Required Required
97024 Application of a modality to 1 or more areas; diathermy (e.g., microwave)
Required Required
97026 Application of a modality to 1 or more areas; infrared
Required Required
97028 Application of a modality to 1 or more areas; ultraviolet
Required Required
97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
Required Required
97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes
Required Required
97034 Application of a modality to one or more areas; contrast baths, each 15 minutes
Required Required
97035 Application of a modality to one or more areas; ultrasound, each 15 minutes
Required Required
Rev 07/26/2013 48
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
97036 Application of a modality to one or more areas; Hubbard tank, each 15 minutes
Required Required
97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Required Required
97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Required Required
97113 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
Required Required
97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)
Required Required
97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
Required Required
97140 Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
Required Required
97150 Therapeutic procedure(s), group (2 or more individuals)
Required Required
S8940 Equestrian/hippotherapy, per session Required Required
S8990 Physical or manipulative therapy performed for maintenance rather than restoration
Required Required
Platelet Rich Plasma Policy 2.01.24 P9020 Platelet Rich Plasma, each unit Required Required
0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
Required Required
Pneumatic Compressors
Non-Segmental
Policy 1.01.17
E0650 Pneumatic compressor; non-segmental home model
Required Required
E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure
Required Required
E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure
Required Required
E0655 Non-segmental pneumatic home appliance for use with pneumatic compressor; half arm
Required Required
E0656 Segmental pneumatic appliance for use with a pneumatic compressor, trunk
Required Required
Rev 07/26/2013 49
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
E0657` Segmental pneumatic appliance for use with a pneumatic compressor, chest
Required Required
E0660 Non-segmental pneumatic appliance for use with pneumatic compressor; full leg
Required Required
E0665 Full arm Required Required E0667 Segmental pneumatic appliance for use with
pneumatic compressor; full leg Required Required
E0668 Full arm Required Required
E0669 Half leg Required Required
E0671 Segmental gradient pressure pneumatic appliance, full leg
Required Required
E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)
Required Required
E0676 Intermittent limb compression device (includes all accessories), not otherwise specified
Required Required
Posturograph Policy 2.01.20
92548 Computerized dynamic posturography Required Required Prolotherapy Policy 8.01.10
M0076 Proton Beam Radiation Policy 6.01.11
77520 Proton treatment delivery; simple without compensation
Required Required
77522 Proton treatment delivery; simple with compensation
Required Required
77523 Proton treatment delivery; intermediate Required Required 77525 Proton treatment delivery; complex Required Required
Prosthetics Devices - Per
Policy 1.01.18
L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
Required for Computerized
Prosthetic legs; “C” legs and
Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
Required for Computerized
Prosthetic legs; “C” legs and
Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
Rev 07/26/2013 50
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
L5857 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor (s) , any type
Required for Computerized
Prosthetic legs; “C” legs and
Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
Required for Computerized
Prosthetic legs; “C” legs and
Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
L5858 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor (s), any type
Required for Computerized
Prosthetic legs; “C” legs and
Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
Required for Computerized
Prosthetic legs; “C” legs and
Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
L5859 Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor (s)
Required for Computerized
Prosthetic legs; “C” legs and Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
Required for Computerized
Prosthetic legs; “C” legs and Miscellaneous and Unlisted “L” Codes, or
unless member contract
limitations apply
Psychological Testing Policy 3.01.02
96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
Required Required
96102 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to- face
Required Required
Rev 07/26/2013 51
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
96103 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report
Required Required
Revenue Code 918 Psychiatric/Psychological Services - Testing Required Required
Radiofrequency Tumor
Ablation
Policy 7.01.32
32998 Ablation therapy for reduction or eradication of one or more pulmonary tumor( s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency,
l l
Required Required
47382 Ablation, one or more liver tumor( s), percutaneous, radiofrequency
Required Required
Rhinoplasty/Septoplasty InterQual
30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
Required Required
30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
Required Required
30420 Rhinoplasty, primary; including major septal repair Required Required
30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
Required Required
30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
Required Required
30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
Required Required
30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only
Required Required
30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies
Required Required
Sacral Nerve Stimulation Policy 7.01.10
64561 Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
Required Required
Rev 07/26/2013 52
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
Required Required
64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
Required Required
64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
Required Required
L8680 Implantable neurostimulator electrode, each Required Required L8681 Patient programmer (external) for use with
implantable programmable neurostimulator pulse generator, replacement only
Required Required
L8682 Implantable neurostimulator radiofrequency receiver
Required Required
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
Required Required
L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement
Required Required
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
Required Required
L8686 implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
Required Required
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
Required Required
L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
Required Required
L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only
Required Required
Sexual Re-assignment
S
Policy 7.01.84
55970 Intersex surgery; male to female Required Required
55980 Intersex surgery; female to male Required Required
56805 Clitoroplasty for intersex state Required Required
57335 Vaginoplasty for intersex state Required Required
Skin Substitutes Policy 7.01.35
Q4107 Skin substitute, graftjacket, per square centimeter Required Required
Rev 07/26/2013 53
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Q4111 Skin substitute, gammagraft, per square centimeter
Required Required
Q4122 Dermacell, per square centimeter Required Required
Q4123 Alloskin RT, per square centimeter Required Required Q4124 Oasis Ultra Tri-Layer wound matrix, per square
centimeter Required Required
Q4125 Arthroflex, per square centimeter Required Required
Q4126 Memoderm, per square centimeter Required Required
Q4127 Talymed, per square centimeter Required Required Q4128 FLEXHD or Allopatch HD, per square centimeter Required Required
Q4129 Unite Biomatrix, per square centimeter Required Required
Q4130 Strattice TM, per square centimeter Required Required
Q4131 (Replaced deleted code C9366)
EpiFix, per sq cm Required Required
Sleep Studies (Safety Net and
Medicare Advantage
Policy 2.01.28
94762 Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)
Required for Medicare only
Required
95800 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g. by airflow or peripheral arterial tone) and sleep time
Required for Medicare only
Required
95801 Sleep study, unattended, simultaneous minimum recording; heart rate, oxygen saturation, respiratory analysis (e.g. by airflow or peripheral arterial tone) and sleep time
Required for Medicare only
Required
95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
Required for Medicare only
Required
95806 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist
Required for Medicare only
Required
95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
Required for Medicare only
Required
95808 Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist
Required for Medicare only
Required
95810 Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist
Required for Medicare only
Required
Rev 07/26/2013 54
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
95811 Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi- level ventilation, attended by a technologist
Required for Medicare only
Required
G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels; EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
Required for Medicare only
Required
G0399 Home Sleep test (HST) with type II portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart
Required for Medicare only
Required
G0400 Home Sleep test (HST) with type IV v portable monitor, unattended; minimum of 3 channels
Required for Medicare only
Required
Speech Generating Devices Policy 1.01.03 E1902 Communication board, non-electric augmentative
or alternative communication device Required Required
E2500 Speech generating device, digitized speech, using pre-recorded messages, less t than or equal to 8 minutes recording time
Required Required
E2502 Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time
Required Required
E2504 Speech generating device, digitized speech, using pre-recorded messages greater than 20 minutes but less than or equal to 40 minutes recording time
Required Required
E2506 Speech generating device, digitized speech, using pre-recorded messages, greater then 40 minutes recording time
Required Required
E2508 Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with device
Required Required
E2510 Speech generating device, synthesized speech, permitting multiple ,methods of message formulation and multiple methods of device access
Required Required
E2512 Accessory for speech generating device. Mounting
Required Required
E2599 Accessory for speech generating device, not otherwise classified
Required Required
Speech Therapy Policy 8.01.13 92507 Treatment of speech, language, voice,
communication, and/or auditory processing disorder; individual
Required Required
92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
Required Required
Rev 07/26/2013 55
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
92526 Treatment of swallowing dysfunction and/or oral function for feeding
Required Required
S9152 Speech therapy re-evaluation Required Required
Spinal Cord Stimulation Policy 7.01.51
63650 Percutaneous implantation of neurostimulator electrode array, epidural
Required Required
63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
Required Required
63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
Required Required
L8680 Implantable neurostimulator electrode, each Required Required
L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
Required Required
L8682 Implantable neurostimulator radiofrequency receiver
Required Required
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
Required Required
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
Required Required
L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
Required Required
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
Required Required
L8688 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
Required Required
L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only
Required Required
Stander/ Standing Device Policy 1.01.46
E0638 Standing frame system, one position (e.g., Upright, supine or prone stander), any size including pediatric, with or without wheels
Required Required
E0641 Standing frame system, multi-position (e.g., Three way stander), any size including pediatric, with or without wheels
Required Required
Rev 07/26/2013 56
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
E0642 Standing frame system, mobile (dynamic stander), any size including pediatric
Required Required
L1510 THKAO, Standing frame, with or without tray and accessories
Required Required
Stereotactic Radiosurgery Policy 6.01.12 32701 Thoracic target (s) delineation for
Stereotactic Body Radiation Therapy (SRS/SBRT), (Photon or Particle beam), entire course
Required Required
77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion (s) consisting of 1 session; multi- source Cobalt 60 based
Required Required
77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion (s) consisting of 1 session; linear accelerator based
Required Required
77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
Required Required
77432 Stereotactic radiation treatment management of cranial lesion (s) (complete course of treatment consisting of 1 session)
Required Required
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
Required Required
61796 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
Required Required
61797 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure)
Required Required
61798 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion
Required Required
61799 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure)
Required Required
61800 Application of stereotactic head frame for stereotactic radiosurgery (List separately in addition to code for primary procedure)
Required Required
63620 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
Required Required
Rev 07/26/2013 57
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
63621 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)
Required Required
G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session
Required Required
G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five sessions per course of treatment
Required Required
G0339 Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment
Required Required
G0340 Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment
Required Required
Surgical Management of
Sleep disorders
Policy 7.01.41
41512 Tongue base suspension, permanent suture technique
Required Required
T.E.N.S. Units Policy 1.01.01
E0720 TENS device; two lead, localized stimulation Required Required
E0730 TENS device; four or more leads, for multiple nerve stimulation
Required Required
E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
Required Required
Traction Devices;
P ti
Policy 1.01.47
E0849 Traction equipment, cervical, free standing stand/frame, pneumatic, applying traction force to other than mandible
Required Required
Transplants Multiple Policies: see policy list for individual procedures
0289T Corneal incisions in the donor cornea created using a laser, in preparation for penetrating or lamellar Keratoplasty (list separately in addition to the code for the primary procedure)
Required Required
Rev 07/26/2013 58
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
0290T Corneal incisions in the recipient cornea created using a laser, in preparation for penetrating or lamellar Keratoplasty (list separately in addition to code for the Primary procedure)
Required Required
32851 Lung transplant, single; without cardiopulmonary bypass
Required Required
32852 Lung transplant, single; with cardiopulmonary bypass
Required Required
32853 Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass
Required Required
32854 Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass
Required Required
32855 Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral
Required Required
32856 Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral
Required Required
33933 Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation
Required Required
33935 Heart-lung transplant with recipient cardiectomy- pneumonectomy
Required Required
33944 Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and
Required Required
33945 Heart transplant, with or without recipient cardiectomy
Required Required
38205 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic
Required Required
38206 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
Required Required
38210 Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion
Required Required
38211 Transplant preparation of hematopoietic progenitor cells; tumor cell depletion
Required Required
Rev 07/26/2013 59
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
38212 Transplant preparation of hematopoietic progenitor cells; red blood cell removal
Required Required
38213 Transplant preparation of hematopoietic progenitor cells; platelet depletion
Required Required
38230 Bone marrow harvesting for transplantation Required Required
38232 Bone marrow harvesting for transplantation; autologousborne marrow harvesting for transplantation, autologous
Required Required
38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic
Required Required
38241 Bone marrow or blood-derived peripheral stem cell transplantation; autologous
Required Required
44133 Donor enterectomy (including cold preservation), open; partial, from living donor
Required Required
44135 Intestinal allotransplantation; from cadaver donor Required Required
44136 Intestinal allotransplantation; from living donor Required Required
47135 Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age
Required Required
47136 Living heterotopic, partial or whole, from cadaver or living donor, any age
Required Required
47143 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split
Required Required
47144 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into two partial liver grafts (i.e., left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII])
Required Required
Rev 07/26/2013 60
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
47145 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into two partial liver grafts (i.e., left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII])
Required Required
47146 Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each
Required Required
47147 Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each
Required Required
48552 Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each
Required Required
48554 Transplantation of pancreatic allograft Required Required
48556 Removal of transplanted pancreatic allograft Required Required
50320 Donor nephrectomy (including cold preservation); open, from living donor
Required Required
50323 Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary
Required Required
50327 Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each
Required Required
50340 Recipient nephrectomy (separate procedure) Required Required
50360 Renal allotransplantation, implantation of graft; without recipient nephrectomy
Required Required
50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy
Required Required
50370 Removal of transplanted renal allograft Required Required
50380 Renal autotransplantation, reimplantation of kidney
Required Required
S2053 Transplantation of small intestine and liver allografts
Required Required
S2054 Transplantation of multivisceral organs Required Required S2065 Simultaneous pancreas kidney transplantation Required Required
Rev 07/26/2013 61
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
S2150 Bone marrow or blood-derived stem cells (peripheral or umbilical), allogenic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre and post-transplant care in the global definition
Required Required
S2152 Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical /surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre-and post-transplant care in the global definition
Required Required
Vagus Nerve Stimulation Policy 7.01.05
61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
Required Required
61888 Revision or removal of cranial neurostimulator pulse generator or receiver
Required Required
64553 Percutaneous implantation of neurostimulator electrodes; cranial nerve
Required Required
64568 Incision for implantation of cranial nerve (e.g. vagus nerve) neurostimulator electrode array pulse generator
Required Required
L8680 Implantable neurostimulator electrode, each Required Required L8681 Patient programmer (external) for use with
implantable programmable neurostimulator pulse generator, replacement only
Required Required
L8682 Implantable neurostimulator radiofrequency receiver
Required Required
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
Required Required
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
Required Required
L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
Required Required
Rev 07/26/2013 62
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
Varicose Vein Treatments (includes
Ligation, Sclerosing and
Policy 7.01.47
36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
Required Required
36469 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face
Required Required
36470 Injection of sclerosing solution; single vein Required Required 36471 Injection of sclerosing solution; multiple veins,
same leg Required Required
36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
Required Required
36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
Required Required
36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser, first vein treated
Required Required
36479 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
Required Required
37500 Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)
Required Required
37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions
Required Required
37718 Ligation, division, and stripping, short saphenous vein
Required Required
37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below
Required Required
37735 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia
Required Required
37760 Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open
Required Required
Rev 07/26/2013 63
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
37761 Ligation of Perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg
Required Required
37765 Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions
Required Required
37766 Stab phlebectomy of varicose veins, one extremity; more than 20 incisions
Required Required
37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
Required Required
37785 Ligation, division, and/or excision of varicose vein cluster(s), one leg
Required Required
S2202 Echosclerotherapy Required Required Vertebral Corpectomy InterQual
63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment
Required Required
63082 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure)
Required Required
Vertebroplasty; Percutaneous
Policy 6.01.17
22520 Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic
Required Required
22521 Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; lumbar
Required Required
Vision Services (eyewear and prosthetic appliances)
Safety Net Only
92071 Fitting of contact lens for treatment of ocular surface disease
Not Required Required
92072 Fitting of contact lens for management of Keratoconus, initial fitting
Not Required Required
S0580 Polycarbonate lens (list in addition to basic code for lenses)
Not Required Required
V2121 Lenticular lens, per lens, single Not Required Required
V2199 Not otherwise classified, single vision lens Not Required Required
V2221 Lenticular lens, per lens, bifocal Not Required Required
V2299 Specialty bifocal (by report) Not Required Required
Rev 07/26/2013 64
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
V2321 Lenticular lens, per lens. trifocal Not Required Required
V2399 Specialty trifocal (by report) Not Required Required V2410 Variable asphericity lens, single vision, full field,
glass or plastic, per lens Not Required Required
V2430 Variable asphericity lens, bifocal, full field, glass or plastic, per lens
Not Required Required
V2499 Variable sphericity lens, other type Not Required Required V2500 Contact lens, PMMA, spherical, per lens Not Required Required V2501 Contact lens, PMMA, toric or prism ballast, per
lens Not Required Required
V2502 Contact lens, PMMA, bifocal, per lens Not Required Required V2503 Contact lens, PMMA, color vision deficiency, per
lens Not Required Required
V2510 Contact lens, gas permeable, spherical, per lens Not Required Required
V2511 Contact lens, gas permeable, toric, prism ballast, per lens
Not Required Required
V2512 Contact lens, gas permeable, bifocal, per lens Not Required Required V2513 Contact lens, gas permeable, extended wear, per
lens Not Required Required
V2520 Contact lens, hydrophilic, spherical, per lens Not Required Required
V2521 Contact lens, hydrophilic, toric or prism ballast, per lens
Not Required Required
V2522 Contact lens, hydrophilic, bifocal, per lens Not Required Required
V2523 Contact lens, hydrophilic, extended wear, per lens Not Required Required
V2530 Contact lens, scleral, gas impermeable, per lens Not Required Required V2531 Contact lens, scleral, gas permeable, per lens Not Required Required
V2599 Contact lens, other type Not Required Required V2600 Hand Held low vision aids and other nonspectacle
mounted aids Not Required Required
V2610 Single lens spectacle mounted low vision aids Not Required Required V2615 Telescopic and other compound lens system,
including distance vision telescopic, near vision telescopes and compound microscopic lens system
Not Required Required
V2623 Prosthetic eye, plastic, custom Not Required Required
V2624 Polishing/resurfacing of ocular prosthesis Not Required Required
V2625 Enlargement of ocular prosthesis Not Required Required V2626 Reduction of ocular prosthesis Not Required Required
Rev 07/26/2013 65
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
V2627 Scleral cover shell Not Required Required
V2628 Fabrication and fitting of ocular conformer Not Required Required V2629 Prosthetic eye, other type Not Required Required V2700 Balance lens, per lens Not Required Required V2702 Deluxe lens feature Not Required Required V2710 Slab off prism, glass or plastic, per lens Not Required Required V2715 Prism, per lens Not Required Required
V2718 Press-on lens, Fresnel prism, per lens Not Required Required V2755 U-V lens, per lens Not Required Required V2770 Occluder lens, per lens Not Required Required V2780 Oversize lens, per lens Not Required Required
V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens
Not Required Required
V2783 Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens
Not Required Required
V2784 Lens, polycarbonate or equal, any index, per lens Not Required Required
V2785 Processing, preserving and transporting corneal tissue
Not Required Required
V2786 Specialty occupational multifocal lens, per lens Not Required Required
V2788 Presbyopia correcting function of intraocular lens Not Required Required V2790 Amniotic membrane for surgical reconstruction,
per procedure Not Required Required
V2797 Vision supply, accessory and/or service component of another HCPCS vision code
Not Required Required
V2799 Vision service, miscellaneous Not Required Required
Wheelchairs and Power
Policy 1.01.16
E1050 Fully-reclining wheelchair; fixed full length arms, swing away detachable elevating leg rests
Required Required
E1060 Fully-reclining wheelchair; detachable arms, desk or full length, swing away detachable elevating leg rests
Required Required
E1070 Fully-reclining wheelchair; detachable arms, desk or full length, swing away detachable footrest
Required Required
E1083 Hemi-wheelchair; fixed full length arms, swing away detachable elevating leg rest
Required Required
E1084 Hemi-wheelchair; detachable arms desk or full length arms. Swing away detachable elevating leg rests
Required Required
E1085 Hemi-wheelchair; fixed full length arms, swing away detachable elevating leg rest
Required Required
Rev 07/26/2013 66
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
E1086 Hemi-wheelchair; detachable arms desk or full length, swing away detachable footrests
Required Required
E1087 High strength lightweight wheelchair; fixed full length arms, swing away detachable elevating leg rests
Required Required
E1088 High strength lightweight wheelchair, detachable arms desk or full length, swing away detachable elevating leg rests
Required Required
E1089 High strength lightweight wheelchair, fixed length arms, swing away detachable foot rest
Required Required
E1090 High strength lightweight wheelchair, detachable arms desk or full length, swing away detachable footrests
Required Required
E1092 Wide heavy duty wheelchair, detachable arms (desk or full length); swing away detachable elevating leg rests
Required Required
E1093 Wide heavy duty wheelchair, detachable arms (desk or full length); swing away detachable footrests
Required Required
E1100 Semi-reclining wheelchair; fixed full length arms, awing away detachable elevating leg rests
Required Required
E1110 Semi-reclining wheelchair; detachable arms (desk or full length), elevating leg rest
Required Required
E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable leg rests
Required Required
E1140 Wheelchair, detachable arms, desk or full length; swing away detachable footrests
Required Required
E1150 wheelchair, detachable arms, desk or full length; swing away detachable elevating leg rests
Required Required
E1160 wheelchair, fixed full length areas, swing away detachable elevating leg rests
Required Required
E1161 Manual adult size wheelchair, includes tilt In space
Required Required
E1170 Amputee wheelchair; fixed full length arms, swing away detachable elevating leg rests
Required Required
E1171 Amputee wheelchair; fixed full length arms, with foot rests or leg rests
Required Required
E1172 Amputee wheelchair; detachable arms(desk or full length), without foot rests or leg rests
Required Required
E1180 detachable arms (desk or full length) swing away detachable elevating leg rests
Required Required
E1190 detachable arms (desk or full length), swing away detachable elevating leg rests
Required Required
E1195 Heavy duty wheelchair, fixed full length arms, swing away detachable elevating leg rests
Required Required
E1200 Amputee wheelchair, fixed full length arms, swing away detachable foot rest
Required Required
Rev 07/26/2013 67
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
E1220 Wheelchair specially sized or constructed (indicate brand name, model number, if any, and justification)
Required Required
E1221 Wheel chair with fixed arm; footrests Required Required
E1222 elevating leg rests Required Required
E1223 Wheelchair with detachable arms; foot rests Required Required
E1224 elevating leg rests Required Required
E1229 Wheelchair, pediatric size, not otherwise specified Required Required
E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system
Required Required
E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
Required Required
E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
Required Required
E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
Required Required
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system
Required Required
E1236 Wheelchair, pediatric size, folding, adjustable, with seating system
Required Required
E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system
Required Required
E1238 Wheelchair, pediatric size, folding, adjustable, without seating system
Required Required
E1239 Power wheelchair, pediatric size, not otherwise specified
Required Required
E1240 Lightweight wheelchair; detachable arms, (desk or full length) swing away detachable, elevating leg rest
Required Required
E1250 Fixed full length arms, swing away detachable footrest
Required Required
E1260 detachable arms (desk or full length) swing away detachable foot rest
Required Required
E1270 fixed full length arms, swing away detachable elevating leg rests
Required Required
E1280 Heavy duty wheelchair; detachable arms (desk or full length) elevating leg rests
Required Required
E1285 fixed full length arms, swing away detachable foot rest
Required Required
E1290 detachable arms (desk or full length) swing away detachable foot rest
Required Required
Rev 07/26/2013 68
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
E1295 fixed full length arms, elevating leg rest Required Required
E1296 special wheelchair; seat height from floor Required Required
E1297 seat depth, by upholstery Required Required E1298 seat depth and/or width, by construction Required Required
E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each
Required Required
E2230 Manual wheelchair accessory, manual standing system
Required Required
E2231 Manual wheelchair accessory, solid seat support brace (replaces sling seat), includes any type mounting hardware
Required Required
E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features
Required Required
E2312 Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional including fixed mounting hardware
Required Required
E2397 Power wheelchair accessory, lithium based battery, each
Required Required
K0001 Standard wheelchair Required Required K0002 Standard hemi (low seat) wheelchair Required Required
K0003 Lightweight wheelchair; detachable arms, (desk or full length) swing away detachable, elevating leg rest
Required Required
K0004 High strength, lightweight wheelchair Required Required
K0005 Ultra lightweight wheelchair Required Required
K0006 Heavy duty wheelchair Required Required
K0007 Extra heavy duty wheelchair Required Required
K0009 other manual wheelchair/base Required Required
K0010 Standard - weight frame motorized/power wheelchair
Required Required
K0108 Wheelchair component or accessory, not otherwise specified
Required Required
E1230 Power operated vehicle (3 or 4 non-highway) specify brand name and model number
Required Required
E1239 Power wheelchair, pediatric size, not otherwise specified
Required Required
Rev 07/26/2013 69
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
K0011 Standard - weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
Required Required
K0014 Other motorized/power wheelchair base Required Required
K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds
Required Required
K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity 301-450 pounds
Required Required
K0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity 451-600 pounds
Required Required
K0806 Power operated vehicle, group 2 standard patient weight capacity up to and including 300 pounds
Required Required
K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301-450 pounds
Required Required
K0808 Power operated vehicle, group 2 very heavy duty, patient weight capacity 451-600 pounds
Required Required
K0812 Power operated vehicle, not otherwise specified Required Required
K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
Required Required
K0814 Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds
Required Required
K0816 Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0821 Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0822 Power wheelchair, group 2 standard, sling/solid seat/back patient weight capacity up to and including 300 pounds
Required Required
K0823 Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0825 Power wheelchair, group 2 heavy duty, captains chair, seat/back, patient weight capacity of 451 to 600 pounds
Required Required
Rev 07/26/2013 70
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
Required Required
K0827 Power wheelchair, group 2, very heavy duty, captains chair, patient weight capacity 451-600 pounds
Required Required
K0828 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
Required Required
K0829 Power wheelchair, group 2 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
Required Required
K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0836 Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0838 Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
Required Required
K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
Required Required
K0840 Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more
Required Required
K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0842 Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0849 Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds
Required Required
Rev 07/26/2013 71
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity of 301 to 450 pounds
Required Required
K0851 Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity up 201 to 450 pounds
Required Required
K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
Required Required
K0853 Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451-600 pounds
Required Required
K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
Required Required
K0855 Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
Required Required
K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0857 Power wheelchair, group 3 standard, single power option captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0859 Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
Required Required
K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
Required Required
K0861 Power wheelchair, group 3 very heavy duty, single power option, captains chair, patient weight capacity 451 to 600 pounds
Required Required
K0862 Power wheelchair, group 3 heavy duty, multiple power option sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling solid seat/back, patient weight capacity 451 to 600 pounds
Required Required
K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more
Required Required
K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0869 Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds
Required Required
Rev 07/26/2013 72
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
Required Required
K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0878 Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back patient weight 451 to 600 pounds
Required Required
K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Required Required
K0885 Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
Required Required
K0886 Power wheelchair, group 4 heavy duty multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
Required Required
K0890 Power wheelchair, group 5 pediatric, single power option sling/solid seat/back, patient weight capacity up to and including 125 pounds
Required Required
K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight
Required Required
K0898 Power wheelchair, not otherwise specified Required Required
Wireless Capsule Endoscopy for Examination
Policy 6.01.27
91110 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with physician interpretation and report
Required Required
91111 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with physician interpretation and report
Required Required
Wound Vac Policy 1.01.38
A6550 Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
Required Required
A9272 Mechanical wound suction, disposable, includes dressing, all accessories and components, each
Required Required
Rev 07/26/2013 73
Clinical Review Preauthorization
Requirements and Corresponding
Procedure Codes
Description
Commercial
Managed Care and Medicare Products,
Managed Safety
Net Products
E2402 Negative pressure wound therapy electrical pump, stationary or portable
Required Required
G0456 Negative pressure wound therapy, (e.g., vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters
Required Required
G0457 Negative pressure wound therapy, (e.g., vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 square centimeters
Required Required
97605 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
Required Required
97606 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters
Required Required
K0743 Suction pump, home model, portable, for use on wounds
Required Required
K0744 Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 square inches or less.
Required Required
K0745 Absorptive wound dressing for use with suction pump, home model, portable. Pad size 16 square inches but less than or equal to 48 square inches.
Required Required
K0746 Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square inches
Required Required
Yttrium-90; Selective Interal Radiaion Therapy (SIRT)
Policy 7.01.69
A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries
Required Required
S2095 Transcatheter occlusion or embolization for tumor destruction, percutaneous; any method using
Required Required
Rev 07/26/2013 74
This list is not inclusive of all insurance products and procedures requiring preauthorization. Please verify specific coverage requirements before rendering service. Some services, including behavioral health and substance abuse, are not covered benefits under Healthy New York HMO.
Some member contracts may have other restrictions. Not all contracts include all benefits. Payment is based on member contract benefits, eligibility and medical necessity at the time of service. The provider delivering the service is responsible for ensuring that the required Pre-authorization has been obtained and contract is active at time of service. Claims will process according to the member’s benefit plan on the date of service. Failure to obtain the necessary preauthorization may result in the denial of the claim or reduced payment allowance.