Medical Policy Reference List (Commercial) 2021 Benefit Procedure Code List Updated August 2021

EXCEPT AS OTHERWISE NOTED IN THE DATE COLUMN, THESE CODES ARE EFFECTIVE ON OR BEFORE JANUARY 1, 2021.

Our medical policy impacts all our coverage decisions. This list includes Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes that, based on our medical policy, are: - Subject to a medical necessity review, - Candidates for a predetermination, - Not a benefit for our members, - Considered experimental, investigational and unproven (EIU), or - Not on our prior authorization list (with some exceptions based on members’ benefit plans)

This is not an exhaustive list of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.

For information on how to submit a voluntary predetermination request, refer to our Utilization Management section on our website at https://www.bcbsil.com/provider/claims/um.html. Predetermination requests may be submitted via the Availity® Provider Portal (availity.com) using the Availity Attachments tool.

This information is not applicable to services provided to any of our HMO or government programs members.

Procedure Code Groups Procedure Code Group Description

Procedures/services reviewed against Medical Policy Criteria. Submit for predetermination to avoid post-service review. Medical Policy Criteria (MP Criteria) Highlighted procedures/services in this code group may require Prior Authorization per contract agreement.

Non Covered Procedures/services not covered by the Plan. Not subject to pre-service review.

Experimental, Investigational, Procedures/services not reimbursed by the Plan. Not subject to pre-service review. Check EIU policy CPCP028, which is one of our Clinical Payment and Coding Policy (CPCP). Unproven (EIU)

Unlisted or Undefined Procedures/services not specifically defined or classified, maybe subject to contract/clinical review.

PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.

Note: Some codes will appear twice if Ending Date and Effective Date are within the same quarter period. (codes in RED text)

Medical Policy Code Code Description Code Group & Description Medical Policy Title Effective Date Ending Date No. MP Criteria: Procedure/service reviewed against Medical Policy Anesth Spine 00640 Criteria. Submit for predetermination to avoid post-service THE803.016 Manipulation Under Anesthesia _ _ Manipulation review. MP Criteria: Procedure/service reviewed against Medical Policy Anesth Surgery For 00797 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Obesity review. Non Covered: Procedure/service not covered by the Plan. Not 07957 Weight Loss _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Correct Skin Color 6.0 SUR716.001 Cosmetic and Reconstructive Procedures 11920 Criteria. Submit for predetermination to avoid post-service _ _ Cm/< SUR716.011 Reconstructive and Contralateral Mammaplasty review. MP Criteria: Procedure/service reviewed against Medical Policy Correct Skn Color 6.1- SUR716.001 Cosmetic and Reconstructive Procedures 11921 Criteria. Submit for predetermination to avoid post-service _ _ 20.0Cm SUR716.011 Reconstructive and Contralateral Mammaplasty review. MP Criteria: Procedure/service reviewed against Medical Policy Correct Skin Color Ea SUR716.001 Cosmetic and Reconstructive Procedures 11922 Criteria. Submit for predetermination to avoid post-service _ _ 20.0Cm SUR716.011 Reconstructive and Contralateral Mammaplasty review. Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Tx Contour Defects 1 Gender Assignment Surgery and Gender Reassignment Surgery 11950 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Cc/< with Related Services review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Tx Contour Defects 1.1- Gender Assignment Surgery and Gender Reassignment Surgery 11951 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ 5.0Cc with Related Services review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Tx Contour Defects 5.1- Gender Assignment Surgery and Gender Reassignment Surgery 11952 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ 10Cc with Related Services review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 1/83 Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Tx Contour Defects Gender Assignment Surgery and Gender Reassignment Surgery 11954 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ >10.0 Cc with Related Services review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management MP Criteria: Procedure/service reviewed against Medical Policy Insert Tissue 11960 Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Expander(S) review. MP Criteria: Procedure/service reviewed against Medical Policy SUR716.009 Breast Implant, Removal and/or Insertion Rplcmt Tiss Xpndr Perm 11970 Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Implt review. SUR716.011 Reconstructive Breast Surgery Compounded Drug Products RX501.063 Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical Policy Implant Hormone SUR717.001 with Related Services 11980 Criteria. Submit for predetermination to avoid post-service _ _ Pellet(S) RX501.007 Hormone Replacement Therapies (HRT) Using Implanted Pellets for review. RX501.076 Women and Delayed Puberty Testosterone Replacement Therapies Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 with Related Services MP Criteria: Procedure/service reviewed against Medical Policy Insert Drug Implant RX501.007 Hormone Replacement Therapies (HRT) Using Implanted Pellets for 11981 Criteria. Submit for predetermination to avoid post-service _ _ Device RX501.076 Women and Delayed Puberty review. RX501.082 Testosterone Replacement Therapies Treatment of Opioid Dependence Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 with Related Services MP Criteria: Procedure/service reviewed against Medical Policy Remove/Insert Drug RX501.007 Hormone Replacement Therapies (HRT) Using Implanted Pellets for 11983 Criteria. Submit for predetermination to avoid post-service _ _ Implant RX501.076 Women and Delayed Puberty review. RX501.082 Testosterone Replacement Therapies Treatment of Opioid Dependence MP Criteria: Procedure/service reviewed against Medical Policy 15734 Muscle-Skin Graft Trunk Criteria. Submit for predetermination to avoid post-service SUR716.011 Reconstructive and Contralateral Mammaplasty _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Free Fascial Flap 15758 Criteria. Submit for predetermination to avoid post-service SUR701.024 Surgery for Lipedema and Lymphedema _ _ Microvasc review. MP Criteria: Procedure/service reviewed against Medical Policy Adipose-Derived Stem Cells in Autologous Fat Grafting to the Grfg Autol Soft Tiss Dir SUR716.021 15769 Criteria. Submit for predetermination to avoid post-service Breast 1/15/2021 _ Exc SUR716.011 review. Reconstructive Breast Surgery MP Criteria: Procedure/service reviewed against Medical Policy Adipose-Derived Stem Cells in Autologous Fat Grafting to the Grfg Autol Fat Lipo 50 SUR716.021 15771 Criteria. Submit for predetermination to avoid post-service Breast 1/15/2021 _ Cc/< SUR716.011 review. Reconstructive Breast Surgery MP Criteria: Procedure/service reviewed against Medical Policy Adipose-Derived Stem Cells in Autologous Fat Grafting to the Grfg Autol Fat Lipo Ea SUR716.021 15772 Criteria. Submit for predetermination to avoid post-service Breast 1/15/2021 _ Addl SUR716.011 review. Reconstructive Breast Surgery MP Criteria: Procedure/service reviewed against Medical Policy Hair Trnspl 1-15 Punch 15775 Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Grfts review. MP Criteria: Procedure/service reviewed against Medical Policy Hair Trnspl >15 Punch 15776 Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Grafts review. Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures Dermabrasion Total SUR716.001 15780 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Face SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures Dermabrasion SUR716.001 15781 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Segmental Face SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures Dermabrasion Other SUR716.001 15782 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Than Face SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures Dermabrasion Suprfl SUR716.001 15783 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Any Site SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management MP Criteria: Procedure/service reviewed against Medical Policy THE801.028 Cosmetic and Reconstructive Procedures 15786 Abrasion Lesion Single Criteria. Submit for predetermination to avoid post-service SUR716.001 _ _ Gender Assignment Surgery and Gender Reassignment Surgery review. SUR717.001 with Related Services Acne Management MP Criteria: Procedure/service reviewed against Medical Policy THE801.028 Abrasion Lesions Add- Cosmetic and Reconstructive Procedures 15787 Criteria. Submit for predetermination to avoid post-service SUR716.001 _ _ On Gender Assignment Surgery and Gender Reassignment Surgery review. SUR717.001 with Related Services Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Chemical Peels Chemical Peel Face SUR716.018 15788 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Epiderm SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Chemical Peels Chemical Peel Face SUR716.018 15789 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Dermal SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 2/83 Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Chemical Peels SUR716.018 15792 Chemical Peel Nonfacial Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Chemical Peels SUR716.018 15793 Chemical Peel Nonfacial Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ SUR717.001 review. with Related Services THE801.030 Nonpharmacologic Treatment of Rosacea MP Criteria: Procedure/service reviewed against Medical Policy Blepharoplasty, Blepharoptosis and Brow Repair Revision Of Lower SUR716.004 15820 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Eyelid SUR717.001 review. with Related Services MP Criteria: Procedure/service reviewed against Medical Policy Blepharoplasty, Blepharoptosis and Brow Repair Revision Of Lower SUR716.004 15821 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Eyelid SUR717.001 review. with Related Services MP Criteria: Procedure/service reviewed against Medical Policy Blepharoplasty, Blepharoptosis and Brow Repair Revision Of Upper SUR716.004 15822 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Eyelid SUR717.001 review. with Related Services MP Criteria: Procedure/service reviewed against Medical Policy Blepharoplasty, Blepharoptosis and Brow Repair Revision Of Upper SUR716.004 15823 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Eyelid SUR717.001 review. with Related Services Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical SUR716.001 Removal Of Forehead Gender Assignment Surgery and Gender Reassignment Surgery 15824 Policy Criteria, may require Prior Authorization per contract SUR717.001 _ _ Wrinkles with Related Services agreement. SUR712.031 Surgical Deactivation of Headache Trigger Sites MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures Removal Of Neck SUR716.001 15825 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Wrinkles SUR717.001 review. with Related Services Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical SUR716.001 Removal Of Brow Gender Assignment Surgery and Gender Reassignment Surgery 15826 Policy Criteria, may require Prior Authorization per contract SUR717.001 _ _ Wrinkles with Related Services agreement. SUR712.031 Surgical Deactivation of Headache Trigger Sites MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures Removal Of Face SUR716.001 15828 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Wrinkles SUR717.001 review. with Related Services MP Criteria: Procedure/service reviewed against Medical Policy Removal Of Skin 15829 Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Wrinkles review. Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Gender Assignment Surgery and Gender Reassignment Surgery 15830 Exc Skin Abd Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Excise Excessive Skin Gender Assignment Surgery and Gender Reassignment Surgery 15832 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Thigh with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Excise Excessive Skin Gender Assignment Surgery and Gender Reassignment Surgery 15833 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Leg with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Excise Excessive Skin Gender Assignment Surgery and Gender Reassignment Surgery 15834 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Hip with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Excise Excessive Skin Gender Assignment Surgery and Gender Reassignment Surgery 15835 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Buttck with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Excise Excessive Skin Gender Assignment Surgery and Gender Reassignment Surgery 15836 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Arm with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Excise Excess Skin Gender Assignment Surgery and Gender Reassignment Surgery 15837 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Arm/Hand with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Excise Excess Skin Fat Gender Assignment Surgery and Gender Reassignment Surgery 15838 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Pad with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures SUR716.001 MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Excise Excess Skin & SUR717.001 15839 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Tissue SUR701.024 review. Surgery for Lipedema and Lymphedema SUR716.017 Surgical Treatment of Gynecomastia MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Cosmetic and Reconstructive Procedures 15847 Exc Skin Abd Add-On Criteria. Submit for predetermination to avoid post-service _ _ SUR701.024 Surgery for Lipedema and Lymphedema review. Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Suction Lipectomy Gender Assignment Surgery and Gender Reassignment Surgery 15876 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Head&Neck with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Suction Lipectomy Gender Assignment Surgery and Gender Reassignment Surgery 15877 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Trunk with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 3/83 Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Suction Lipectomy Upr Gender Assignment Surgery and Gender Reassignment Surgery 15878 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Extrem with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Cosmetic and Reconstructive Procedures MP Criteria: Procedure/service reviewed against Medical Policy SUR716.001 Suction Lipectomy Lwr Gender Assignment Surgery and Gender Reassignment Surgery 15879 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Extrem with Related Services review. SUR701.024 Surgery for Lipedema and Lymphedema Removal Of Pressure Unlisted: Procedure/service not specifically defined or 15999 _ _ _ _ Sore classified, maybe subject to contract/clinical review. Acne Management MP Criteria: Procedure/service reviewed against Medical Policy THE801.028 Destruction Of Skin Laser Treatment of Congenital Port Wine Stain (PWS), 17106 Criteria. Submit for predetermination to avoid post-service SUR704.008 _ _ Lesions Hemangiomas, and Other External Vascular Malformations review. THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management MP Criteria: Procedure/service reviewed against Medical Policy THE801.028 Destruction Of Skin Laser Treatment of Congenital Port Wine Stain (PWS), 17107 Criteria. Submit for predetermination to avoid post-service SUR704.008 _ _ Lesions Hemangiomas, and Other External Vascular Malformations review. THE801.030 Nonpharmacologic Treatment of Rosacea Acne Management MP Criteria: Procedure/service reviewed against Medical Policy THE801.028 Destruction Of Skin Laser Treatment of Congenital Port Wine Stain (PWS), 17108 Criteria. Submit for predetermination to avoid post-service SUR704.008 _ _ Lesions Hemangiomas, and Other External Vascular Malformations review. THE801.030 Nonpharmacologic Treatment of Rosacea EIU: Procedure/service not reimbursed by the Plan. Not subject 17340 Cryotherapy Of Skin to pre-service review. Check EIU policy CPCP028, which is one THE801.028 Acne Management _ _ of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy 17360 Skin Peel Therapy Criteria. Submit for predetermination to avoid post-service THE801.028 Acne Management _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures Hair Removal By SUR716.001 17380 Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ Electrolysis SUR717.001 review. with Related Services Unlisted: Procedure/service not specifically defined or 17999 Skin Tissue Procedure _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than 19105 Cryosurg Ablate Fa Each Criteria. Submit for predetermination to avoid post-service SUR701.018 _ _ Liver, Prostate, or Dermatologic Tumors review. MP Criteria: Procedure/service reviewed against Medical Policy Removal Of Breast 19300 Criteria. Submit for predetermination to avoid post-service SUR716.017 Surgical Treatment of Gynecomastia _ _ Tissue review. MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 19303 Mast Simple Complete Criteria. Submit for predetermination to avoid post-service with Related Services _ _ SUR716.015 review. Risk-Reducing (Prophylactic) Mastectomy Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical SUR717.001 with Related Services 19316 Suspension Of Breast Policy Criteria, may require Prior Authorization per contract SUR716.010 _ _ Mastopexy agreement. SUR716.011 Reconstructive and Contralateral Mammaplasty Cosmetic and Reconstructive Procedures SUR716.001 MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 19318 Breast Reduction Policy Criteria, may require Prior Authorization per contract with Related Services _ _ SUR716.011 agreement. Reconstructive and Contralateral Mammaplasty SUR716.012 Reduction Mammoplasty MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 19324 Enlarge Breast Policy Criteria, may require Prior Authorization per contract with Related Services _ 12/31/2020 SUR716.011 agreement. Reconstructive and Contralateral Mammaplasty MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Breast Augmentation SUR717.001 19325 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ W/Implt SUR716.011 review. Reconstructive and Contralateral Mammaplasty MP Criteria: Procedure/service reviewed against Medical Policy Rmvl Intact Breast SUR716.009 Breast Implant, Removal and/or Insertion 19328 Criteria. Submit for predetermination to avoid post-service _ _ Implant SUR716.011 Reconstructive and Contralateral Mammaplasty review. MP Criteria: Procedure/service reviewed against Medical Policy Rmvl Ruptured Breast SUR716.009 Breast Implant, Removal and/or Insertion 19330 Criteria. Submit for predetermination to avoid post-service _ _ Implant SUR716.011 Reconstructive and Contralateral Mammaplasty review. Breast Implant, Removal and/or Insertion MP Criteria: Procedure/service reviewed against Medical Policy SUR716.009 Insj Breast Implt Sm D Gender Assignment Surgery and Gender Reassignment Surgery 19340 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Mast with Related Services review. SUR716.011 Reconstructive and Contralateral Mammaplasty Breast Implant, Removal and/or Insertion MP Criteria: Procedure/service reviewed against Medical Policy SUR716.009 Insj/Rplcmt Brst Implt Gender Assignment Surgery and Gender Reassignment Surgery 19342 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Sep D with Related Services review. SUR716.011 Reconstructive and Contralateral Mammaplasty MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 19350 Breast Reconstruction Criteria. Submit for predetermination to avoid post-service with Related Services _ _ SUR716.011 review. Reconstructive and Contralateral Mammaplasty MP Criteria: Procedure/service reviewed against Medical Policy Correct Inverted 19355 Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Nipple(S) review. MP Criteria: Procedure/service reviewed against Medical Policy Tiss Xpndr Plmt Brst 19357 Criteria. Submit for predetermination to avoid post-service SUR716.011 Reconstructive and Contralateral Mammaplasty _ _ Rcnstj review. MP Criteria: Procedure/service reviewed against Medical Policy Brst Rcnstj Latsms Drsi 19361 Criteria. Submit for predetermination to avoid post-service SUR716.011 Reconstructive and Contralateral Mammaplasty _ _ Flap review. MP Criteria: Procedure/service reviewed against Medical Policy 19364 Brst Rcnstj Free Flap Criteria. Submit for predetermination to avoid post-service SUR716.011 Reconstructive and Contralateral Mammaplasty _ _ review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 4/83 MP Criteria: Procedure/service reviewed against Medical Policy Revj Peri-Implt Capsule 19370 Criteria. Submit for predetermination to avoid post-service SUR716.011 Reconstructive and Contralateral Mammaplasty _ _ Brst review. MP Criteria: Procedure/service reviewed against Medical Policy Peri-Implt Capslc Brst SUR716.009 Breast Implant, Removal and/or Insertion 19371 Criteria. Submit for predetermination to avoid post-service _ _ Compl SUR716.011 Reconstructive and Contralateral Mammaplasty review. Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast SUR716.021 MP Criteria: Procedure/service reviewed against Medical Policy Handheld Radiofrequency Spectroscopy for Intraoperative Breast Surgery SUR701.037 19499 Criteria. Submit for predetermination to avoid post-service Assessment of Surgical Margins During Breast-Conserving Surgery _ _ Procedure SUR701.031 review. Magnetic Resonance Image Guided Laser Interstitial Tumor SUR716.011 Therapy (LITT) Reconstructive and Contralateral Mammaplasty MP Criteria: Procedure/service reviewed against Medical Policy Inj Dupuytren Cord 20527 Criteria. Submit for predetermination to avoid post-service RX501.073 Clostridial Collagenase for Fibroproliferative Disorders _ _ W/Enzyme review. EIU: Procedure/service not reimbursed by the Plan. Not subject Ndl Insj W/O Njx 1 Or 2 20560 to pre-service review. Check EIU policy CPCP028, which is one SUR702.018 Dry Needling of Trigger Points for Myofascial Pain _ _ Musc of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Ndl Insj W/O Njx 3+ 20561 to pre-service review. Check EIU policy CPCP028, which is one SUR702.018 Dry Needling of Trigger Points for Myofascial Pain _ _ Musc of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy 20979 Us Bone Stimulation Criteria. Submit for predetermination to avoid post-service DME101.030 Low Intensity Pulsed Ultrasound Fracture Healing Device _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Ablate Bone Tumor(S) 20982 Criteria. Submit for predetermination to avoid post-service SUR701.021 Radiofrequency Ablation (RFA) of Solid Tumors, Excluding Liver _ _ Perq review. MP Criteria: Procedure/service reviewed against Medical Policy Ablate Bone Tumor(S) Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than 20983 Criteria. Submit for predetermination to avoid post-service SUR701.018 _ _ Perq Liver, Prostate, or Dermatologic Tumors review. EIU: Procedure/service not reimbursed by the Plan. Not subject 20985 Cptr-Asst Dir Ms Px to pre-service review. Check EIU policy CPCP028, which is one SUR705.023 Computer-Assisted Navigation for Orthopedic Procedures _ _ of our Clinical Payment and Coding Policy (CPCP). Musculoskeletal Unlisted: Procedure/service not specifically defined or 20999 _ _ _ _ Surgery classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy THE803.016 Manipulation Under Anesthesia 21073 Mnpj Of Tmj W/Anesth Criteria. Submit for predetermination to avoid post-service _ _ SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) review. MP Criteria: Procedure/service reviewed against Medical Policy Prepare Face/Oral 21083 Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Prosthesis review. MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Prepare Face/Oral 21085 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Prosthesis agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) Prepare Face/Oral Unlisted: Procedure/service not specifically defined or 21089 _ _ _ _ Prosthesis classified, maybe subject to contract/clinical review. Cosmetic and Reconstructive Procedures SUR716.001 Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical Policy SUR717.001 with Related Services 21120 Reconstruction Of Chin Criteria. Submit for predetermination to avoid post-service SUR705.030 _ _ Orthognathic Surgery review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) Cosmetic and Reconstructive Procedures SUR716.001 Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical Policy SUR717.001 with Related Services 21121 Reconstruction Of Chin Criteria. Submit for predetermination to avoid post-service SUR705.030 _ _ Orthognathic Surgery review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) Cosmetic and Reconstructive Procedures SUR716.001 Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical Policy SUR717.001 with Related Services 21122 Reconstruction Of Chin Criteria. Submit for predetermination to avoid post-service SUR705.030 _ _ Orthognathic Surgery review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) Cosmetic and Reconstructive Procedures SUR716.001 Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical Policy SUR717.001 with Related Services 21123 Reconstruction Of Chin Criteria. Submit for predetermination to avoid post-service SUR705.030 _ _ Orthognathic Surgery review. SUR706.009 Sleep Related Breathing Disorders: Surgical Management SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery Augmentation Lower SUR717.001 21125 Policy Criteria, may require Prior Authorization per contract with Related Services _ _ Jaw Bone SUR705.030 agreement. Orthognathic Surgery Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical SUR717.001 Augmentation Lower with Related Services 21127 Policy Criteria, may require Prior Authorization per contract SUR705.030 _ _ Jaw Bone Orthognathic Surgery agreement. SUR706.009 Sleep Related Breathing Disorders: Surgical Management MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Lefort I-1 Piece W/O 21141 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Graft agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD)

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 5/83 MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Lefort I-2 Piece W/O 21142 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Graft agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Lefort I-3/> Piece W/O 21143 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Graft agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical Lefort I-1 Piece W/ SUR705.030 Orthognathic Surgery 21145 Policy Criteria, may require Prior Authorization per contract _ _ Graft SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) agreement. MP Criteria: Procedure/service reviewed against Medical Lefort I-2 Piece W/ SUR705.030 Orthognathic Surgery 21146 Policy Criteria, may require Prior Authorization per contract _ _ Graft SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) agreement. MP Criteria: Procedure/service reviewed against Medical Lefort I-3/> Piece W/ SUR705.030 Orthognathic Surgery 21147 Policy Criteria, may require Prior Authorization per contract _ _ Graft SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) agreement. MP Criteria: Procedure/service reviewed against Medical Lefort Ii Anterior 21150 Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ Intrusion agreement. MP Criteria: Procedure/service reviewed against Medical 21151 Lefort Ii W/Bone Grafts Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ agreement. MP Criteria: Procedure/service reviewed against Medical 21154 Lefort Iii W/O Lefort I Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ agreement. MP Criteria: Procedure/service reviewed against Medical 21155 Lefort Iii W/ Lefort I Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Lefort Iii W/Fhdw/O 21159 Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ Lefort I agreement. MP Criteria: Procedure/service reviewed against Medical Lefort Iii W/Fhd W/ 21160 Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ Lefort I agreement. MP Criteria: Procedure/service reviewed against Medical Reconstruction Of 21188 Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ Midface agreement. MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Reconst Lwr Jaw W/O 21193 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Graft agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Reconst Lwr Jaw 21194 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ W/Graft agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Reconst Lwr Jaw W/O 21195 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Fixation agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Reconst Lwr Jaw 21196 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ W/Fixation agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Reconstr Lwr Jaw 21198 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Segment agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical SUR705.030 Orthognathic Surgery Reconstr Lwr Jaw 21199 Policy Criteria, may require Prior Authorization per contract SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ W/Advance agreement. SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) MP Criteria: Procedure/service reviewed against Medical Reconstruct Upper Jaw 21206 Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ Bone agreement. MP Criteria: Procedure/service reviewed against Medical Augmentation Of Facial 21208 Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ Bones agreement. MP Criteria: Procedure/service reviewed against Medical Reduction Of Facial 21209 Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ Bones agreement. MP Criteria: Procedure/service reviewed against Medical SUR705.028 Neuralgia Inducing Cavitational Osteonecrosis (NICO) 21210 Face Bone Graft Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ agreement. SUR706.009 Sleep Related Breathing Disorders: Surgical Management MP Criteria: Procedure/service reviewed against Medical SUR705.028 Neuralgia Inducing Cavitational Osteonecrosis (NICO) 21215 Lower Jaw Bone Graft Policy Criteria, may require Prior Authorization per contract SUR705.030 Orthognathic Surgery _ _ agreement. SUR706.009 Sleep Related Breathing Disorders: Surgical Management MP Criteria: Procedure/service reviewed against Medical Policy Reconstruction Of 21244 Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Lower Jaw review. MP Criteria: Procedure/service reviewed against Medical Policy 21246 Reconstruction Of Jaw Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ review. Non Covered: Procedure/service not covered by the Plan. Not 21248 Reconstruction Of Jaw _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 21249 Reconstruction Of Jaw _ _ _ _ subject to pre-service review. Cranio/Maxillofacial Unlisted: Procedure/service not specifically defined or 21299 _ _ _ _ Surgery classified, maybe subject to contract/clinical review. Head Surgery Unlisted: Procedure/service not specifically defined or 21499 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Hyoid Myotomy & 21685 Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Suspension review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 6/83 Neck/Chest Surgery Unlisted: Procedure/service not specifically defined or 21899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy 22505 Manipulation Of Spine Criteria. Submit for predetermination to avoid post-service THE803.016 Manipulation Under Anesthesia _ _ review. EIU: Procedure/service not reimbursed by the Plan. Not subject Prescrl Fuse W/ Instr L5- 22586 to pre-service review. Check EIU policy CPCP028, which is one SUR712.038 Axial Lumbosacral Interbody Fusion _ _ S0 of our Clinical Payment and Coding Policy (CPCP). Spine Surgery Unlisted: Procedure/service not specifically defined or 22899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Abdomen Surgery Unlisted: Procedure/service not specifically defined or 22999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Reconstruct Shoulder 23470 Policy Criteria, may require Prior Authorization per contract SUR705.032 Shoulder Resurfacing _ _ Joint agreement. MP Criteria: Procedure/service reviewed against Medical Policy Shoulder Surgery 23929 Criteria. Submit for predetermination to avoid post-service SUR705.032 Shoulder Resurfacing _ _ Procedure review. MP Criteria: Procedure/service reviewed against Medical Policy Manipulate Elbow 24300 Criteria. Submit for predetermination to avoid post-service THE803.016 Manipulation Under Anesthesia _ _ W/Anesth review. Upper Arm/Elbow Unlisted: Procedure/service not specifically defined or 24999 _ _ _ _ Surgery classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Manipulate Wrist 25259 Criteria. Submit for predetermination to avoid post-service THE803.016 Manipulation Under Anesthesia _ _ W/Anesthes review. Forearm Or Wrist Unlisted: Procedure/service not specifically defined or 25999 _ _ _ _ Surgery classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Manipulate Finger 26340 Criteria. Submit for predetermination to avoid post-service THE803.016 Manipulation Under Anesthesia _ _ W/Anesth review. MP Criteria: Procedure/service reviewed against Medical Policy Manipulat Palm Cord 26341 Criteria. Submit for predetermination to avoid post-service RX501.073 Clostridial Collagenase for Fibroproliferative Disorders _ _ Post Inj review. Unlisted: Procedure/service not specifically defined or 26989 Hand/Finger Surgery _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Manipulation Of Hip 27275 Criteria. Submit for predetermination to avoid post-service THE803.016 Manipulation Under Anesthesia _ _ Joint review. MP Criteria: Procedure/service reviewed against Medical Arthrodesis Sacroiliac 27279 Policy Criteria, may require Prior Authorization per contract SUR705.033 Sacroiliac Joint Fusion or Stabilization _ _ Joint agreement. MP Criteria: Procedure/service reviewed against Medical Fusion Of Sacroiliac 27280 Policy Criteria, may require Prior Authorization per contract SUR705.033 Sacroiliac Joint Fusion or Stabilization _ _ Joint agreement. SUR702.017 Facet Joint and Sacroiliac Joint Denervation MP Criteria: Procedure/service reviewed against Medical SUR705.019 Hip Resurfacing (HR) 27299 Pelvis/Hip Joint Surgery Policy Criteria, may require Prior Authorization per contract _ _ SUR705.036 Surgery for Groin Pain in Athletes agreement. SUR705.029 Surgical Treatment of Femoroacetabular Impingement (FAI) MP Criteria: Procedure/service reviewed against Medical Autochondrocyte Autologous Chondrocyte Implantation (ACI) for Focal Articular 27412 Policy Criteria, may require Prior Authorization per contract SUR705.035 _ _ Implant Knee Cartilage Lesions agreement. MP Criteria: Procedure/service reviewed against Medical Osteochondral Knee Autografts and Allografts in the Treatment of Focal Articular 27415 Policy Criteria, may require Prior Authorization per contract SUR705.020 _ _ Allograft Cartilage Lesions agreement. Unlisted: Procedure/service not specifically defined or 27599 Leg Surgery Procedure _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy 27702 Reconstruct Ankle Joint Criteria. Submit for predetermination to avoid post-service SUR705.021 Total Ankle Replacement (TAR) _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Reconstruction Ankle 27703 Criteria. Submit for predetermination to avoid post-service SUR705.021 Total Ankle Replacement (TAR) _ _ Joint review. MP Criteria: Procedure/service reviewed against Medical Policy 27860 Fixation Of Ankle Joint Criteria. Submit for predetermination to avoid post-service THE803.016 Manipulation Under Anesthesia _ _ review. Leg/Ankle Surgery Unlisted: Procedure/service not specifically defined or 27899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Osteochondral Talus Autografts and Allografts in the Treatment of Focal Articular 28446 Policy Criteria, may require Prior Authorization per contract SUR705.020 _ _ Autogrft Cartilage Lesions agreement. EIU: Procedure/service not reimbursed by the Plan. Not subject Hi Enrgy Eswt Plantar Extracorporeal Shock Wave Therapy for Musculoskeletal 28890 to pre-service review. Check EIU policy CPCP028, which is one SUR705.018 _ _ Fascia Indications and Soft Tissue Injuries of our Clinical Payment and Coding Policy (CPCP). Foot/Toes Surgery Unlisted: Procedure/service not specifically defined or 28899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Casting/Strapping Unlisted: Procedure/service not specifically defined or 29799 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Autografts and Allografts in the Treatment of Focal Articular MP Criteria: Procedure/service reviewed against Medical Autgrft Implnt Knee SUR705.020 Cartilage Lesions 29866 Policy Criteria, may require Prior Authorization per contract _ _ W/Scope SUR705.035 Autologous Chondrocyte Implantation (ACI) for Focal Articular agreement. Cartilage Lesions

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 7/83 MP Criteria: Procedure/service reviewed against Medical Policy Allgrft Implnt Knee Autografts and Allografts in the Treatment of Focal Articular 29867 Criteria. Submit for predetermination to avoid post-service SUR705.020 _ _ W/Scope Cartilage Lesions review. MP Criteria: Procedure/service reviewed against Medical Hip Arthro 29914 Policy Criteria, may require Prior Authorization per contract SUR705.029 Surgical Treatment of Femoroacetabular Impingement (FAI) _ _ W/Femoroplasty agreement. MP Criteria: Procedure/service reviewed against Medical Hip Arthro 29915 Policy Criteria, may require Prior Authorization per contract SUR705.029 Surgical Treatment of Femoroacetabular Impingement (FAI) _ _ Acetabuloplasty agreement. MP Criteria: Procedure/service reviewed against Medical Hip Arthro W/Labral 29916 Policy Criteria, may require Prior Authorization per contract SUR705.029 Surgical Treatment of Femoroacetabular Impingement (FAI) _ _ Repair agreement. Surgical Treatment of Femoroacetabular Impingement (FAI) MP Criteria: Procedure/service reviewed against Medical Policy SUR705.029 Thermal Capsulorrhaphy as a Treatment of Joint Instability 29999 Arthroscopy Of Joint Criteria. Submit for predetermination to avoid post-service SUR705.041 _ _ Unicondylar Interpositional Spacer as a Treatment of review. SUR705.024 Unicompartmental Arthritis of the Knee MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 30400 Reconstruction Of Nose Policy Criteria, may require Prior Authorization per contract with Related Services _ _ SUR706.001 agreement. Nasal and Sinus Surgery MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 30410 Reconstruction Of Nose Policy Criteria, may require Prior Authorization per contract with Related Services _ _ SUR706.001 agreement. Nasal and Sinus Surgery MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 30420 Reconstruction Of Nose Policy Criteria, may require Prior Authorization per contract with Related Services _ _ SUR706.001 agreement. Nasal and Sinus Surgery MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 30430 Revision Of Nose Policy Criteria, may require Prior Authorization per contract with Related Services _ _ SUR706.001 agreement. Nasal and Sinus Surgery MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 30435 Revision Of Nose Policy Criteria, may require Prior Authorization per contract with Related Services _ _ SUR706.001 agreement. Nasal and Sinus Surgery MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 30450 Revision Of Nose Policy Criteria, may require Prior Authorization per contract with Related Services _ _ SUR706.001 agreement. Nasal and Sinus Surgery EIU: Procedure/service not reimbursed by the Plan. Not subject Rpr Nsl Vlv Collapse 30468 to pre-service review. Check EIU policy CPCP028, which is one SUR706.017 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse 5/15/2021 _ W/Implt of our Clinical Payment and Coding Policy (CPCP).

Unlisted: Procedure/service not specifically defined or Nasal Surgery 30999 classified, maybe subject to contract/clinical review. May _ _ _ _ Procedure require Prior Authorization per contract agreement.

Unlisted: Procedure/service not specifically defined or Sinus Surgery 31299 classified, maybe subject to contract/clinical review. May _ _ _ _ Procedure require Prior Authorization per contract agreement. Larynx Surgery Unlisted: Procedure/service not specifically defined or 31599 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Bronch W/Balloon Endoscopic, Arthroscopic, Laparoscopic, Bronchoscopic and 31634 Criteria. Submit for predetermination to avoid post-service SUR701.014 _ _ Occlusion Thoracoscopic Surgery review. MP Criteria: Procedure/service reviewed against Medical Policy Bronchial Valve Init 31647 Criteria. Submit for predetermination to avoid post-service SUR706.015 Bronchial Valves _ _ Insert review. MP Criteria: Procedure/service reviewed against Medical Policy Bronchial Valve Remov 31648 Criteria. Submit for predetermination to avoid post-service SUR706.015 Bronchial Valves _ _ Init review. MP Criteria: Procedure/service reviewed against Medical Policy Bronchial Valve Remov 31649 Criteria. Submit for predetermination to avoid post-service SUR706.015 Bronchial Valves _ _ Addl review. MP Criteria: Procedure/service reviewed against Medical Policy Bronchial Valve Addl 31651 Criteria. Submit for predetermination to avoid post-service SUR706.015 Bronchial Valves _ _ Insert review. Airways Surgical Unlisted: Procedure/service not specifically defined or 31899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Ablate Pulm Tumor Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than 32994 Criteria. Submit for predetermination to avoid post-service SUR701.018 _ _ Perq Crybl Liver, Prostate, or Dermatologic Tumors review. MP Criteria: Procedure/service reviewed against Medical Policy Ablate Pulm Tumor SUR701.038 Microwave Tumor Ablation 32998 Criteria. Submit for predetermination to avoid post-service _ _ Perq Rf SUR701.021 Radiofrequency Ablation (RFA) of Solid Tumors, Excluding Liver review. Chest Surgery Unlisted: Procedure/service not specifically defined or 32999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Insert Card Electrodes Biventricular Pacemakers (Cardiac Resynchronization Therapy) for 33211 Criteria. Submit for predetermination to avoid post-service MED202.054 _ _ Dual the Treatment of Heart Failure review. MP Criteria: Procedure/service reviewed against Medical Policy Insert Pulse Gen Dual Biventricular Pacemakers (Cardiac Resynchronization Therapy) for 33213 Criteria. Submit for predetermination to avoid post-service MED202.054 _ _ Leads the Treatment of Heart Failure review. MP Criteria: Procedure/service reviewed against Medical Policy L Ventric Pacing Lead Biventricular Pacemakers (Cardiac Resynchronization Therapy) for 33225 Criteria. Submit for predetermination to avoid post-service MED202.054 _ _ Add-On the Treatment of Heart Failure review. MP Criteria: Procedure/service reviewed against Medical Policy Tcat Insj/Rpl Perm Ldls 33274 Criteria. Submit for predetermination to avoid post-service SUR707.030 Leadless Cardiac Pacemaker _ _ Pm review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 8/83 MP Criteria: Procedure/service reviewed against Medical Policy Tcat Rmvl Perm Ldls Pm 33275 Criteria. Submit for predetermination to avoid post-service SUR707.030 Leadless Cardiac Pacemaker _ _ W/Img review. MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Insj Subq Car Rhythm 33285 Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and _ _ Mntr review. Intracardiac Ischemia Detection Systems) MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Rmvl Subq Car Rhythm 33286 Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and _ 3/31/2021 Mntr review. Intracardiac Ischemia Detection Systems) MP Criteria: Procedure/service reviewed against Medical Policy Tcat Impl Wrls P-Art Prs Cardiac Hemodynamic Monitoring for the Management of Heart 33289 Criteria. Submit for predetermination to avoid post-service MED202.058 _ _ Snr Failure in the Outpatient Setting review. MP Criteria: Procedure/service reviewed against Medical Policy Replace Aortic Valve 33363 Criteria. Submit for predetermination to avoid post-service SUR707.028 Transcatheter Aortic-Valve Implantation for Aortic Stenosis _ _ Open review. MP Criteria: Procedure/service reviewed against Medical Policy Replace Aortic Valve 33364 Criteria. Submit for predetermination to avoid post-service SUR707.028 Transcatheter Aortic-Valve Implantation for Aortic Stenosis _ _ Open review. MP Criteria: Procedure/service reviewed against Medical Policy Trcath Replace Aortic 33366 Criteria. Submit for predetermination to avoid post-service SUR707.028 Transcatheter Aortic-Valve Implantation for Aortic Stenosis _ _ Valve review. MP Criteria: Procedure/service reviewed against Medical Policy Replace Aortic Valve 33367 Criteria. Submit for predetermination to avoid post-service SUR707.028 Transcatheter Aortic-Valve Implantation for Aortic Stenosis _ _ W/Byp review. MP Criteria: Procedure/service reviewed against Medical Policy Replace Aortic Valve 33368 Criteria. Submit for predetermination to avoid post-service SUR707.028 Transcatheter Aortic-Valve Implantation for Aortic Stenosis _ _ W/Byp review. MP Criteria: Procedure/service reviewed against Medical Policy Removal Of Heart 33542 Criteria. Submit for predetermination to avoid post-service SUR707.026 Cardiac Restoration and Remodeling Procedures _ _ Lesion review. MP Criteria: Procedure/service reviewed against Medical Policy Restore/Remodel 33548 Criteria. Submit for predetermination to avoid post-service SUR707.026 Cardiac Restoration and Remodeling Procedures _ _ Ventricle review. MP Criteria: Procedure/service reviewed against Medical Policy Impltj Tot Rplcmt Hrt 33927 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Sys review. MP Criteria: Procedure/service reviewed against Medical Policy Rmvl & Rplcmt Tot Hrt 33928 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Sys review. MP Criteria: Procedure/service reviewed against Medical Policy Rmvl Rplcmt Hrt Sys 33929 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ F/Trnspl review. Cardiac Restoration and Remodeling Procedures SUR707.026 Percutaneous and Surgical Closure of the Left Atrial Appendage for Cardiac Surgery Unlisted: Procedure/service not specifically defined or 33999 SUR701.009 Stroke Prevention in Atrial Fibrillation _ _ Procedure classified, maybe subject to contract/clinical review. SUR703.027 Stem-Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia Vessel Injection Unlisted: Procedure/service not specifically defined or 36299 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Njx Noncmpnd Sclrsnt 1 36465 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Vein review. MP Criteria: Procedure/service reviewed against Medical Policy Njx Noncmpnd Sclrsnt 36466 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Mlt Vn review. MP Criteria: Procedure/service reviewed against Medical Policy 36468 Njx Sclrsnt Spider Veins Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Njx Sclrsnt 1 Incmptnt 36470 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Vein review. MP Criteria: Procedure/service reviewed against Medical Policy Njx Sclrsnt Mlt Incmptnt 36471 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Vn review. EIU: Procedure/service not reimbursed by the Plan. Not subject Endovenous Mchnchem 36473 to pre-service review. Check EIU policy CPCP028, which is one SUR707.016 Varicose Vein Management _ _ 1St Vein of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Endovenous Mchnchem 36474 to pre-service review. Check EIU policy CPCP028, which is one SUR707.016 Varicose Vein Management _ _ Add-On of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy 36475 Endovenous Rf 1St Vein Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Endovenous Rf Vein 36476 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Add-On review. MP Criteria: Procedure/service reviewed against Medical Policy Endovenous Laser 1St 36478 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Vein review. MP Criteria: Procedure/service reviewed against Medical Policy Endovenous Laser Vein 36479 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Addon review. MP Criteria: Procedure/service reviewed against Medical Policy Endoven Ther Chem 36482 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Adhes 1St review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 9/83 MP Criteria: Procedure/service reviewed against Medical Policy Endoven Ther Chem 36483 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Adhes Sbsq review. MP Criteria: Procedure/service reviewed against Medical Apheresis Immunoads 36516 Policy Criteria, may require Prior Authorization per contract THE802.003 Lipid Apheresis _ _ Slctv agreement. MP Criteria: Procedure/service reviewed against Medical Policy 36522 Photopheresis Criteria. Submit for predetermination to avoid post-service THE801.026 Extracorporeal Photopheresis (ECP) _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Transcath Stent Cca 37215 Criteria. Submit for predetermination to avoid post-service SUR701.028 Extracranial Carotid Angioplasty or Stenting _ _ W/Eps review. MP Criteria: Procedure/service reviewed against Medical Policy Transcath Stent Cca 37216 Criteria. Submit for predetermination to avoid post-service SUR701.028 Extracranial Carotid Angioplasty or Stenting _ _ W/O Eps review. MP Criteria: Procedure/service reviewed against Medical Policy Stent Placemt Retro 37217 Criteria. Submit for predetermination to avoid post-service SUR701.028 Extracranial Carotid Angioplasty or Stenting _ _ Carotid review. MP Criteria: Procedure/service reviewed against Medical Policy Stent Placemt Ante 37218 Criteria. Submit for predetermination to avoid post-service SUR701.028 Extracranial Carotid Angioplasty or Stenting _ _ Carotid review. MP Criteria: Procedure/service reviewed against Medical Policy Vasc Embolize/Occlude Therapeutic Embolization and Vessel Occlusion to Treat Pelvic 37241 Criteria. Submit for predetermination to avoid post-service SUR701.015 _ _ Venous Conditions review. MP Criteria: Procedure/service reviewed against Medical Policy Vasc Embolize/Occlude Therapeutic Embolization and Vessel Occlusion to Treat Pelvic 37242 Criteria. Submit for predetermination to avoid post-service SUR701.015 _ _ Artery Conditions review.

Radioembolization for Primary and Metastatic Tumors of the Liver MP Criteria: Procedure/service reviewed against Medical Policy RAD601.047 Vasc Embolize/Occlude Therapeutic Embolization and Vessel Occlusion to Treat Pelvic 37243 Criteria. Submit for predetermination to avoid post-service SUR701.015 _ _ Organ Conditions review. THE801.022 Transcatheter Arterial Chemoembolization (TACE) of the Liver

MP Criteria: Procedure/service reviewed against Medical Policy Vasc Embolize/Occlude Therapeutic Embolization and Vessel Occlusion to Treat Pelvic 37244 Criteria. Submit for predetermination to avoid post-service SUR701.015 _ _ Bleed Conditions review. MP Criteria: Procedure/service reviewed against Medical Policy Endoscopy Ligate Perf 37500 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Veins review. Vascular Endoscopy Unlisted: Procedure/service not specifically defined or 37501 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy 37700 Revise Leg Vein Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Ligate/Strip Short Leg 37718 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Vein review. MP Criteria: Procedure/service reviewed against Medical Policy Ligate/Strip Long Leg 37722 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Vein review. MP Criteria: Procedure/service reviewed against Medical Policy Removal Of Leg 37735 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Veins/Lesion review. MP Criteria: Procedure/service reviewed against Medical Policy 37760 Ligate Leg Veins Radical Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy 37761 Ligate Leg Veins Open Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Stab Phleb Veins Xtr 10- 37765 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ 19 review. MP Criteria: Procedure/service reviewed against Medical Policy Phleb Veins - Extrem 37766 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ 20+ review. MP Criteria: Procedure/service reviewed against Medical Policy 37780 Revision Of Leg Vein Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Ligate/Divide/Excise 37785 Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ Vein review. Vascular Surgery Unlisted: Procedure/service not specifically defined or 37799 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Laparoscope Proc Unlisted: Procedure/service not specifically defined or 38129 _ _ _ _ Spleen classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 10/83 Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion Following Preparative Regimens (General Donor and Recipient SUR703.037 Information) SUR703.002 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.043 Lymphoblastic Leukemia (ALL) SUR703.047 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.036 Syndrome (AIDS) SUR703.038 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.039 Hematopoietic Cell Transplantation for Breast Cancer SUR703.029 Hematopoietic Cell Transplantation for Central Nervous System SUR703.041 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Policy SUR703.034 Bl Donor Search Hematopoietic Cell Transplantation for Chronic Lymphocytic 38204 Criteria. Submit for predetermination to avoid post-service SUR703.033 _ _ Management Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) review. SUR703.040 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.042 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.035 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.032 Acquired Anemias SUR703.031 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.030 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.046 and Gliomas SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.002 Information) SUR703.043 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.047 Lymphoblastic Leukemia (ALL) SUR703.036 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.038 Syndrome (AIDS) SUR703.039 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.029 Hematopoietic Cell Transplantation for Breast Cancer SUR703.041 Hematopoietic Cell Transplantation for Central Nervous System SUR703.034 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Policy Harvest Allogeneic SUR703.033 Hematopoietic Cell Transplantation for Chronic Lymphocytic 38205 Criteria. Submit for predetermination to avoid post-service _ _ Stem Cell SUR703.040 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) review. SUR703.042 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.035 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.032 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.031 Acquired Anemias SUR703.030 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.046 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.044 and Gliomas SUR703.050 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.045 in Adults SUR703.051 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.002 Information) SUR703.043 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.047 Lymphoblastic Leukemia (ALL) SUR703.036 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.038 Syndrome (AIDS) SUR703.039 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.029 Hematopoietic Cell Transplantation for Breast Cancer SUR703.041 Hematopoietic Cell Transplantation for Central Nervous System SUR703.034 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical SUR703.033 Hematopoietic Cell Transplantation for Chronic Lymphocytic 38206 Harvest Auto Stem Cells Policy Criteria, may require Prior Authorization per contract _ _ SUR703.040 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) agreement. SUR703.042 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.035 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.032 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.031 Acquired Anemias SUR703.030 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.046 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.044 and Gliomas SUR703.050 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.045 in Adults SUR703.051 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias,

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 11/83 Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Cryopreserve Stem Leukemia (AML) 38207 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Cells Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Thaw Preserved Stem Leukemia (AML) 38208 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Cells Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Wash Harvest Stem Leukemia (AML) 38209 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Cells Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias,

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 12/83 Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 T-Cell Depletion Of Leukemia (AML) 38210 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Harvest Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Tumor Cell Deplete Of Leukemia (AML) 38211 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Harvst Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Rbc Depletion Of Leukemia (AML) 38212 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Harvest Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias,

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 13/83 Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Platelet Deplete Of Leukemia (AML) 38213 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Harvest Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Volume Deplete Of Leukemia (AML) 38214 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Harvest Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Harvest Stem Cell Leukemia (AML) 38215 Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Concentrte Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias,

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 14/83 Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.043 Syndrome (AIDS) SUR703.047 Hematopoietic Cell Transplantation for Breast Cancer SUR703.038 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.029 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.042 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.002 and Gliomas SUR703.037 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.036 Following Preparative Regimens (General Donor and Recipient SUR703.039 Information) SUR703.041 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Bone Marrow Harvest SUR703.034 Leukemia (AML) 38230 Policy Criteria, may require Prior Authorization per contract _ _ Allogen SUR703.033 Hematopoietic Cell Transplantation for Autoimmune Diseases agreement. SUR703.040 Hematopoietic Cell Transplantation for Central Nervous System SUR703.035 Embryonal Tumors and Ependymoma SUR703.032 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.031 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.030 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.046 Acquired Anemias SUR703.044 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.050 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.045 in Adults SUR703.051 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.043 Syndrome (AIDS) SUR703.047 Hematopoietic Cell Transplantation for Breast Cancer SUR703.038 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.029 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.042 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.002 and Gliomas SUR703.037 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.036 Following Preparative Regimens (General Donor and Recipient SUR703.039 Information) SUR703.041 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy Bone Marrow Harvest SUR703.034 Leukemia (AML) 38232 Criteria. Submit for predetermination to avoid post-service _ _ Autolog SUR703.033 Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.040 Hematopoietic Cell Transplantation for Central Nervous System SUR703.035 Embryonal Tumors and Ependymoma SUR703.032 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.031 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.030 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.046 Acquired Anemias SUR703.044 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.050 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.045 in Adults SUR703.051 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation as a Treatment of Acute Lymphoblastic Leukemia (ALL) Hematopoietic Cell Transplantation for Acquired Immunodeficiency Syndrome (AIDS) SUR703.043 Hematopoietic Cell Transplantation for Breast Cancer SUR703.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic SUR703.038 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) SUR703.029 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.042 and Gliomas SUR703.002 Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.036 Information) SUR703.039 Hematopoietic Cell Transplantation for Acute Myelogenous MP Criteria: Procedure/service reviewed against Medical Policy SUR703.041 Leukemia (AML) 38240 Transplt Allo Hct/Donor Criteria. Submit for predetermination to avoid post-service SUR703.034 _ _ Hematopoietic Cell Transplantation for Autoimmune Diseases review. SUR703.033 Hematopoietic Cell Transplantation for Central Nervous System SUR703.040 Embryonal Tumors and Ependymoma SUR703.035 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.032 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.031 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.030 Acquired Anemias SUR703.046 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias,

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 15/83 Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion SUR703.037 Following Preparative Regimens (General Donor and Recipient SUR703.002 Information) SUR703.043 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.047 Lymphoblastic Leukemia (ALL) SUR703.036 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.038 Syndrome (AIDS) SUR703.039 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.029 Hematopoietic Cell Transplantation for Breast Cancer SUR703.041 Hematopoietic Cell Transplantation for Central Nervous System SUR703.034 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Transplt Autol SUR703.033 Hematopoietic Cell Transplantation for Chronic Lymphocytic 38241 Policy Criteria, may require Prior Authorization per contract _ _ Hct/Donor SUR703.040 Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) agreement. SUR703.042 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.035 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.032 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.031 Acquired Anemias SUR703.030 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.046 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.044 and Gliomas SUR703.050 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.045 in Adults SUR703.051 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion Following Preparative Regimens (General Donor and Recipient SUR703.037 Information) SUR703.002 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.043 Lymphoblastic Leukemia (ALL) SUR703.047 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.036 Syndrome (AIDS) SUR703.038 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.039 Hematopoietic Cell Transplantation for Breast Cancer SUR703.029 Hematopoietic Cell Transplantation for Central Nervous System SUR703.041 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Policy SUR703.034 Transplt Allo Hematopoietic Cell Transplantation for Chronic Lymphocytic 38242 Criteria. Submit for predetermination to avoid post-service SUR703.033 _ _ Lymphocytes Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) review. SUR703.040 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.042 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.035 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.032 Acquired Anemias SUR703.031 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.030 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.046 and Gliomas SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion Following Preparative Regimens (General Donor and Recipient SUR703.037 Information) SUR703.002 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.043 Lymphoblastic Leukemia (ALL) SUR703.047 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.036 Syndrome (AIDS) SUR703.038 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.039 Hematopoietic Cell Transplantation for Breast Cancer SUR703.029 Hematopoietic Cell Transplantation for Central Nervous System SUR703.041 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Policy SUR703.034 Transplj Hematopoietic Hematopoietic Cell Transplantation for Chronic Lymphocytic 38243 Criteria. Submit for predetermination to avoid post-service SUR703.033 _ _ Boost Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) review. SUR703.040 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.042 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.035 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.032 Acquired Anemias SUR703.031 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.030 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.046 and Gliomas SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, MP Criteria: Procedure/service reviewed against Medical Policy Incision Of Lymph 38308 Criteria. Submit for predetermination to avoid post-service SUR701.024 Surgery for Lipedema and Lymphedema _ _ Channels review. Laparoscope Proc Unlisted: Procedure/service not specifically defined or 38589 _ _ _ _ Lymphatic classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 16/83 Blood/Lymph System Unlisted: Procedure/service not specifically defined or 38999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 39499 Chest Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Diaphragm Surgery Unlisted: Procedure/service not specifically defined or 39599 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 40799 Lip Surgery Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Mouth Surgery Unlisted: Procedure/service not specifically defined or 40899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Tongue Base Vol SUR701.021 Radiofrequency Ablation (RFA) of Solid Tumors, Excluding Liver 41530 to pre-service review. Check EIU policy CPCP028, which is one _ _ Reduction SUR706.009 Sleep Related Breathing Disorders: Surgical Management of our Clinical Payment and Coding Policy (CPCP). Tongue And Mouth Unlisted: Procedure/service not specifically defined or 41599 _ _ _ _ Surgery classified, maybe subject to contract/clinical review. Excision Gum Each Non Covered: Procedure/service not covered by the Plan. Not 41820 _ _ _ _ Quadrant subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41821 Excision Of Gum Flap _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41822 Excision Of Gum Lesion _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41823 Excision Of Gum Lesion _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41828 Excision Of Gum Lesion _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41830 Removal Of Gum Tissue _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41870 Gum Graft _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41872 Repair Gum _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 41874 Repair Tooth Socket _ _ _ _ subject to pre-service review. Dental Surgery Unlisted: Procedure/service not specifically defined or 41899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Repair Palate 42145 Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Pharynx/Uvula review. Unlisted: Procedure/service not specifically defined or 42299 Palate/Uvula Surgery _ _ _ _ classified, maybe subject to contract/clinical review. Salivary Surgery Unlisted: Procedure/service not specifically defined or 42699 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Throat Surgery Unlisted: Procedure/service not specifically defined or 42999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Esoph Optical 43206 to pre-service review. Check EIU policy CPCP028, which is one MED201.038 Confocal Laser Endomicroscopy (CLE) _ _ Endomicroscopy of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Egd Esophagogastrc 43210 Criteria. Submit for predetermination to avoid post-service MED201.016 Device Therapies for Gastroesophageal Reflux Disease (GERD) _ _ Fndoplsty review. MP Criteria: Procedure/service reviewed against Medical Policy SUR716.003 Bariatric Surgery Uppr Gi Scope 43236 Criteria. Submit for predetermination to avoid post-service RX501.019 Botulinum Toxin _ _ W/Submuc Inj review. MED201.016 Device Therapies for Gastroesophageal Reflux Disease (GERD)

EIU: Procedure/service not reimbursed by the Plan. Not subject Egd Optical 43252 to pre-service review. Check EIU policy CPCP028, which is one MED201.038 Confocal Laser Endomicroscopy (CLE) _ _ Endomicroscopy of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Egd Us Transmural 43253 Criteria. Submit for predetermination to avoid post-service MED201.016 Device Therapies for Gastroesophageal Reflux Disease (GERD) _ _ Injxn/Mark review. MP Criteria: Procedure/service reviewed against Medical Policy Egd W/Thrml Txmnt 43257 Criteria. Submit for predetermination to avoid post-service MED201.016 Device Therapies for Gastroesophageal Reflux Disease (GERD) _ _ Gerd review. MP Criteria: Procedure/service reviewed against Medical Policy Laps Esophgl Sphnctr Magnetic Esophageal Ring to Treat Gastroesophageal Reflux 43284 Criteria. Submit for predetermination to avoid post-service SUR709.036 _ _ Agmntj Disease (GERD) review. Unlisted: Procedure/service not specifically defined or 43289 Laparoscope Proc Esoph MED201.016 Device Therapies for Gastroesophageal Reflux Disease (GERD) _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or Esophagus Surgery 43499 classified, maybe subject to contract/clinical review. May _ _ _ _ Procedure require Prior Authorization per contract agreement. MP Criteria: Procedure/service reviewed against Medical Policy Removal Of Stomach 43633 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Partial review. MP Criteria: Procedure/service reviewed against Medical Policy Lap Gastric 43644 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Bypass/Roux-En-Y review. MP Criteria: Procedure/service reviewed against Medical Policy Lap Gastr Bypass Incl 43645 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Smll I review. MP Criteria: Procedure/service reviewed against Medical Lap Impl Electrode 43647 Policy Criteria, may require Prior Authorization per contract SUR709.031 Gastric Electrical Stimulation (GES) _ _ Antrum agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 17/83 MP Criteria: Procedure/service reviewed against Medical Lap Revise/Remv Eltrd 43648 Policy Criteria, may require Prior Authorization per contract SUR709.031 Gastric Electrical Stimulation (GES) _ _ Antrum agreement. Unlisted: Procedure/service not specifically defined or 43659 Laparoscope Proc Stom _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Lap Place Gastr Adj 43770 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Device review. MP Criteria: Procedure/service reviewed against Medical Policy Lap Revise Gastr Adj 43771 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Device review. MP Criteria: Procedure/service reviewed against Medical Policy Lap Rmvl Gastr Adj 43772 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Device review. MP Criteria: Procedure/service reviewed against Medical Policy Lap Replace Gastr Adj 43773 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Device review. MP Criteria: Procedure/service reviewed against Medical Policy Lap Rmvl Gastr Adj All 43774 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Parts review. MP Criteria: Procedure/service reviewed against Medical Policy 43775 Lap Sleeve Gastrectomy Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy 43842 V-Band Gastroplasty Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Gastroplasty W/O V- 43843 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Band review. MP Criteria: Procedure/service reviewed against Medical Policy Gastroplasty Duodenal 43845 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Switch review. MP Criteria: Procedure/service reviewed against Medical Policy Gastric Bypass For 43846 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Obesity review. MP Criteria: Procedure/service reviewed against Medical Policy Gastric Bypass Incl 43847 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Small I review. MP Criteria: Procedure/service reviewed against Medical Policy 43848 Revision Gastroplasty Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ review. MP Criteria: Procedure/service reviewed against Medical Impl/Redo Electrd 43881 Policy Criteria, may require Prior Authorization per contract SUR709.031 Gastric Electrical Stimulation (GES) _ _ Antrum agreement. MP Criteria: Procedure/service reviewed against Medical Policy Revise Gastric Port 43886 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Open review. MP Criteria: Procedure/service reviewed against Medical Policy Remove Gastric Port 43887 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Open review. MP Criteria: Procedure/service reviewed against Medical Policy Change Gastric Port 43888 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Open review. Stomach Surgery Unlisted: Procedure/service not specifically defined or 43999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Laparoscope Proc Unlisted: Procedure/service not specifically defined or 44238 _ _ _ _ Intestine classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Prepare Fecal 44705 Criteria. Submit for predetermination to avoid post-service SUR703.049 Fecal Microbiota Transplantation (FMT) _ _ Microbiota review. Unlisted Px Small Unlisted: Procedure/service not specifically defined or 44799 _ _ _ _ Intestine classified, maybe subject to contract/clinical review. Bowel Surgery Unlisted: Procedure/service not specifically defined or 44899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 44979 Laparoscope Proc App _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted Procedure Unlisted: Procedure/service not specifically defined or 45399 _ _ _ _ Colon classified, maybe subject to contract/clinical review. Laparoscope Proc Unlisted: Procedure/service not specifically defined or 45499 _ _ _ _ Rectum classified, maybe subject to contract/clinical review. Rectum Surgery Unlisted: Procedure/service not specifically defined or 45999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Repair Anorectal Fist 46707 to pre-service review. Check EIU policy CPCP028, which is one SUR709.032 Plugs for Fistula Repair _ _ W/Plug of our Clinical Payment and Coding Policy (CPCP). Unlisted: Procedure/service not specifically defined or 46999 Anus Surgery Procedure _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Laparo Ablate Liver Radiofrequency Ablation (RFA) of Primary or Metastatic Liver 47370 Criteria. Submit for predetermination to avoid post-service SUR709.029 _ _ Tumor Rf Tumors review. MP Criteria: Procedure/service reviewed against Medical Policy Laparo Ablate Liver 47371 Criteria. Submit for predetermination to avoid post-service SUR701.032 Cryosurgical Ablation of Primary or Metastatic Liver Tumors _ _ Cryosurg review. Laparoscope Procedure Unlisted: Procedure/service not specifically defined or 47379 _ _ _ _ Liver classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 18/83 MP Criteria: Procedure/service reviewed against Medical Policy Open Ablate Liver Radiofrequency Ablation (RFA) of Primary or Metastatic Liver 47380 Criteria. Submit for predetermination to avoid post-service SUR709.029 _ _ Tumor Rf Tumors review. MP Criteria: Procedure/service reviewed against Medical Policy Microwave Tumor Ablation SUR701.038 47382 Percut Ablate Liver Rf Criteria. Submit for predetermination to avoid post-service Radiofrequency Ablation (RFA) of Primary or Metastatic Liver _ _ SUR709.029 review. Tumors MP Criteria: Procedure/service reviewed against Medical Policy Perq Abltj Lvr 47383 Criteria. Submit for predetermination to avoid post-service SUR701.032 Cryosurgical Ablation of Primary or Metastatic Liver Tumors _ _ Cryoablation review. Unlisted: Procedure/service not specifically defined or 47399 Liver Surgery Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Laparoscope Proc Unlisted: Procedure/service not specifically defined or 47579 _ _ _ _ Biliary classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or Bile Tract Surgery 47999 classified, maybe subject to contract/clinical review. May AIM Guidelines _ _ _ Procedure require Prior Authorization per contract agreement. Pancreas Surgery Unlisted: Procedure/service not specifically defined or 48999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Laparo Proc Unlisted: Procedure/service not specifically defined or 49329 _ _ _ _ Abdm/Per/Oment classified, maybe subject to contract/clinical review. Laparo Proc Hernia Unlisted: Procedure/service not specifically defined or 49659 _ _ _ _ Repair classified, maybe subject to contract/clinical review. Abdomen Surgery Unlisted: Procedure/service not specifically defined or 49999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Cryoablate Renal Mass Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than 50250 Criteria. Submit for predetermination to avoid post-service SUR701.018 _ _ Open Liver, Prostate, or Dermatologic Tumors review. MP Criteria: Procedure/service reviewed against Medical Policy SUR703.007 Kidney Transplant Transplantation Of 50360 Criteria. Submit for predetermination to avoid post-service SUR703.008 Liver Transplant and Combined Liver-Kidney Transplant _ _ Kidney review. SUR703.013 Pancreas and Related Organ Tissue Transplantation MP Criteria: Procedure/service reviewed against Medical Policy Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Laparo Ablate Renal SUR701.018 50541 Criteria. Submit for predetermination to avoid post-service Liver, Prostate, or Dermatologic Tumors _ _ Cyst SUR701.021 review. Radiofrequency Ablation (RFA) of Solid Tumors, Excluding Liver

MP Criteria: Procedure/service reviewed against Medical Policy Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Laparo Ablate Renal SUR701.018 50542 Criteria. Submit for predetermination to avoid post-service Liver, Prostate, or Dermatologic Tumors _ _ Mass SUR701.021 review. Radiofrequency Ablation (RFA) of Solid Tumors, Excluding Liver Unlisted: Procedure/service not specifically defined or 50549 Laparoscope Proc Renal _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Perc Rf Ablate Renal SUR701.038 Microwave Tumor Ablation 50592 Criteria. Submit for predetermination to avoid post-service _ _ Tumor SUR701.021 Radiofrequency Ablation (RFA) of Solid Tumors, Excluding Liver review. MP Criteria: Procedure/service reviewed against Medical Policy Perc Cryo Ablate Renal Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than 50593 Criteria. Submit for predetermination to avoid post-service SUR701.018 _ _ Tum Liver, Prostate, or Dermatologic Tumors review. Laparoscope Proc Unlisted: Procedure/service not specifically defined or 50949 _ _ _ _ Ureter classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Endoscopic Injectable Bulking Agents for the Treatment of Urinary and Fecal 51715 Criteria. Submit for predetermination to avoid post-service SUR710.008 _ _ Injection/Implant Incontinence review. Unlisted: Procedure/service not specifically defined or 51999 Laparoscope Proc Bla _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Cystoscopy Inject Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux 52327 Criteria. Submit for predetermination to avoid post-service SUR710.022 _ _ Material (VUR) review. MP Criteria: Procedure/service reviewed against Medical Policy Cystourethro Prostatic Urethral Lift (PUL) for the Treatment of Benign Prostatic 52441 Criteria. Submit for predetermination to avoid post-service SUR710.023 _ _ W/Implant Hyperplasia (BPH) review. MP Criteria: Procedure/service reviewed against Medical Policy Cystourethro W/Addl Prostatic Urethral Lift (PUL) for the Treatment of Benign Prostatic 52442 Criteria. Submit for predetermination to avoid post-service SUR710.023 _ _ Implant Hyperplasia (BPH) review. EIU: Procedure/service not reimbursed by the Plan. Not subject Transurethral Rf Radiofrequency Energy Therapy for Stress Urinary Incontinence 53860 to pre-service review. Check EIU policy CPCP028, which is one SUR710.021 _ _ Treatment (SUI) of our Clinical Payment and Coding Policy (CPCP). Urology Surgery Unlisted: Procedure/service not specifically defined or 53899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery 54125 Removal Of Penis Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ with Related Services review. MP Criteria: Procedure/service reviewed against Medical Policy Treatment Of Penis RX501.073 Clostridial Collagenase for Fibroproliferative Disorders 54200 Criteria. Submit for predetermination to avoid post-service _ _ Lesion MED201.030 Sexual Dysfunctions, Assessment and Treatment review. MP Criteria: Procedure/service reviewed against Medical Policy Treatment Of Penis RX501.073 Clostridial Collagenase for Fibroproliferative Disorders 54205 Criteria. Submit for predetermination to avoid post-service _ _ Lesion MED201.030 Sexual Dysfunctions, Assessment and Treatment review. MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Insert Semi-Rigid SUR717.001 54400 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Prosthesis MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Insert Self-Contd SUR717.001 54401 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Prosthesis MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Insert Multi-Comp Penis SUR717.001 54405 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Pros MED201.030 review. Sexual Dysfunctions, Assessment and Treatment

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 19/83 MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Remove Muti-Comp SUR717.001 54406 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Penis Pros MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Repair Multi-Comp SUR717.001 54408 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Penis Pros MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Remove/Replace Penis SUR717.001 54410 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Prosth MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Remov/Replc Penis Pros SUR717.001 54411 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Comp MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Remove Self-Contd SUR717.001 54415 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Penis Pros MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Remv/Repl Penis SUR717.001 54416 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Contain Pros MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery Remv/Replc Penis Pros SUR717.001 54417 Criteria. Submit for predetermination to avoid post-service with Related Services _ _ Compl MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Cosmetic and Reconstructive Procedures SUR716.001 54660 Revision Of Testis Criteria. Submit for predetermination to avoid post-service Gender Assignment Surgery and Gender Reassignment Surgery _ _ SUR717.001 review. with Related Services Unlisted: Procedure/service not specifically defined or 54699 Laparoscope Proc Testis _ _ _ _ classified, maybe subject to contract/clinical review. Laparo Proc Spermatic Unlisted: Procedure/service not specifically defined or 55559 _ _ _ _ Cord classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Prostate Saturation Saturation Biopsy for Diagnosis, Staging and Management of 55706 Criteria. Submit for predetermination to avoid post-service SUR717.015 _ _ Sampling Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy review. MP Criteria: Procedure/service reviewed against Medical Policy 55880 Abltj Mal Prst8 Tiss Hifu Criteria. Submit for predetermination to avoid post-service SUR717.014 High-Intensity Focused Ultrasound (HIFU) for Treatment of Cancer 2/1/2021 _ review. High-Intensity Focused Ultrasound (HIFU) for Treatment of Cancer MP Criteria: Procedure/service reviewed against Medical SUR717.014 Genital Surgery Magnetic Resonance Image Guided Laser Interstitial Tumor 55899 Policy Criteria, may require Prior Authorization per contract SUR701.031 _ _ Procedure Therapy (LITT) agreement. SUR710.019 Nerve Graft With Radical Prostatectomy MP Criteria: Procedure/service reviewed against Medical Policy Sex Transformation M Gender Assignment Surgery and Gender Reassignment Surgery 55970 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ To F with Related Services review. MP Criteria: Procedure/service reviewed against Medical Policy Sex Transformation F To Gender Assignment Surgery and Gender Reassignment Surgery 55980 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ M with Related Services review. MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery 56805 Repair Clitoris Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ with Related Services review. MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 56810 Repair Of Perineum Criteria. Submit for predetermination to avoid post-service with Related Services _ _ MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery 57291 Construction Of Vagina Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ with Related Services review. MP Criteria: Procedure/service reviewed against Medical Policy Construct Vagina With Gender Assignment Surgery and Gender Reassignment Surgery 57292 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Graft with Related Services review. MP Criteria: Procedure/service reviewed against Medical Policy Revise Vag Graft Open Gender Assignment Surgery and Gender Reassignment Surgery 57296 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Abd with Related Services review. MP Criteria: Procedure/service reviewed against Medical Policy Fistula Repair & 57307 Criteria. Submit for predetermination to avoid post-service SUR709.032 Plugs for Fistula Repair _ _ Colostomy review. MP Criteria: Procedure/service reviewed against Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery SUR717.001 57335 Repair Vagina Criteria. Submit for predetermination to avoid post-service with Related Services _ _ MED201.030 review. Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Policy Revise Prosth Vag Graft Gender Assignment Surgery and Gender Reassignment Surgery 57426 Criteria. Submit for predetermination to avoid post-service SUR717.001 _ _ Lap with Related Services review. Unlisted: Procedure/service not specifically defined or 58578 Laparo Proc Uterus _ _ _ _ classified, maybe subject to contract/clinical review. Hysteroscope Unlisted: Procedure/service not specifically defined or 58579 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Laps Abltj Uterine Laparoscopic, Percutaneous and Transcervical Techniques for the 58674 Criteria. Submit for predetermination to avoid post-service SUR701.033 _ _ Fibroids Myolysis of Uterine Fibroids review. Laparo Proc Oviduct- Unlisted: Procedure/service not specifically defined or 58679 _ _ _ _ Ovary classified, maybe subject to contract/clinical review. Genital Surgery Unlisted: Procedure/service not specifically defined or 58999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 59897 Fetal Invas Px W/Us _ _ _ _ classified, maybe subject to contract/clinical review. Laparo Proc Ob Unlisted: Procedure/service not specifically defined or 59898 _ _ _ _ Care/Deliver classified, maybe subject to contract/clinical review. Maternity Care Unlisted: Procedure/service not specifically defined or 59899 _ _ _ _ Procedure classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 20/83 Unlisted: Procedure/service not specifically defined or 60659 Laparo Proc Endocrine _ _ _ _ classified, maybe subject to contract/clinical review. Endocrine Surgery Unlisted: Procedure/service not specifically defined or 60699 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Diagnosis and Treatment of Chronic Cerebrospinal Venous EIU: Procedure/service not reimbursed by the Plan. Not subject MED202.064 Insufficiency in Multiple Sclerosis 61630 Intracranial Angioplasty to pre-service review. Check EIU policy CPCP028, which is one _ _ SUR701.027 Intracranial Stenting or Angioplasty, including Endovascular of our Clinical Payment and Coding Policy (CPCP). Procedures Diagnosis and Treatment of Chronic Cerebrospinal Venous MP Criteria: Procedure/service reviewed against Medical Policy Intracran Angioplsty MED202.064 Insufficiency in Multiple Sclerosis 61635 Criteria. Submit for predetermination to avoid post-service _ _ W/Stent SUR701.027 Intracranial Stenting or Angioplasty, including Endovascular review. Procedures MP Criteria: Procedure/service reviewed against Medical Policy Perq Art M-Thrombect Intracranial Stenting or Angioplasty, including Endovascular 61645 Criteria. Submit for predetermination to avoid post-service SUR701.027 _ _ &/Nfs Procedures review. MP Criteria: Procedure/service reviewed against Medical Deep Brain Stimulation (DBS) Implant SUR712.025 61850 Policy Criteria, may require Prior Authorization per contract Responsive Neurostimulation (RNS) for the Treatment of _ _ Neuroelectrodes SUR712.039 agreement. Refractory Focal Epilepsy Auditory Brainstem Implant MP Criteria: Procedure/service reviewed against Medical SUR714.009 Deep Brain Stimulation (DBS) 61863 Implant Neuroelectrode Policy Criteria, may require Prior Authorization per contract SUR712.025 _ _ Responsive Neurostimulation (RNS) for the Treatment of agreement. SUR712.039 Refractory Focal Epilepsy Auditory Brainstem Implant MP Criteria: Procedure/service reviewed against Medical SUR714.009 Implant Neuroelectrde Deep Brain Stimulation (DBS) 61864 Policy Criteria, may require Prior Authorization per contract SUR712.025 _ _ Addl Responsive Neurostimulation (RNS) for the Treatment of agreement. SUR712.039 Refractory Focal Epilepsy Automated Percutaneous Discectomy and Percutaneous MP Criteria: Procedure/service reviewed against Medical Percutaneous SUR712.004 Endoscopic Discectomy 62287 Policy Criteria, may require Prior Authorization per contract _ _ Diskectomy SUR712.037 Decompression of the Intervertebral Disc Using Laser Energy (Laser agreement. Discectomy) or Radiofrequency Coblation (Nucleoplasty) MP Criteria: Procedure/service reviewed against Medical Implant 64561 Policy Criteria, may require Prior Authorization per contract SUR710.018 Sacral Nerve Neuromodulation/Stimulation _ _ Neuroelectrodes agreement. MP Criteria: Procedure/service reviewed against Medical Policy Neuroeltrd Stim Post 64566 Criteria. Submit for predetermination to avoid post-service MED205.035 Percutaneous Tibial Nerve Stimulation (PTNS) _ _ Tibial review. MP Criteria: Procedure/service reviewed against Medical Implant 64581 Policy Criteria, may require Prior Authorization per contract SUR710.018 Sacral Nerve Neuromodulation/Stimulation _ _ Neuroelectrodes agreement. MP Criteria: Procedure/service reviewed against Medical Policy Injection Treatment Of 64640 Criteria. Submit for predetermination to avoid post-service SUR705.040 Ablation of Peripheral Nerves to Treat Pain 5/15/2021 12/31/2999 Nerve review. MP Criteria: Procedure/service reviewed against Medical Policy Remove Sympathetic 64809 Criteria. Submit for predetermination to avoid post-service MED201.014 Treatment of Hyperhidrosis _ _ Nerves review. Unlisted: Procedure/service not specifically defined or Nervous System 64999 classified, maybe subject to contract/clinical review. May _ _ _ _ Surgery require Prior Authorization per contract agreement. MP Criteria: Procedure/service reviewed against Medical Policy 65760 Revision Of Cornea Criteria. Submit for predetermination to avoid post-service SUR713.001 Refractive and Therapeutic Keratoplasty _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Revise Cornea With 65770 Criteria. Submit for predetermination to avoid post-service OTH903.030 Keratoprosthesis _ _ Implant review. MP Criteria: Procedure/service reviewed against Medical Policy Impltj Ntrstrml Crnl Rng 65785 Criteria. Submit for predetermination to avoid post-service SUR713.031 Implantation of Intrastromal Corneal Ring Segments _ _ Seg review. MP Criteria: Procedure/service reviewed against Medical Policy 66174 Translum Dil Eye Canal Criteria. Submit for predetermination to avoid post-service SUR713.032 Viscocanalostomy and Canaloplasty _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Trnslum Dil Eye Canal 66175 Criteria. Submit for predetermination to avoid post-service SUR713.032 Viscocanalostomy and Canaloplasty _ _ W/Stnt review. MP Criteria: Procedure/service reviewed against Medical Policy Aqueous Shunt Eye 66179 Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ W/O Graft review. MP Criteria: Procedure/service reviewed against Medical Policy Aqueous Shunt Eye 66180 Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma 5/1/2021 12/31/2999 W/Graft review. MP Criteria: Procedure/service reviewed against Medical Policy Insert Ant Drainage 66183 Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ Device review. Unlisted: Procedure/service not specifically defined or 66999 Eye Surgery Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 67299 Eye Surgery Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted Px Extraocular Unlisted: Procedure/service not specifically defined or 67399 _ _ _ _ Musc classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 67599 Orbit Surgery Procedure _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical SUR716.004 Blepharoplasty, Blepharoptosis and Brow Repair 67900 Repair Brow Defect Policy Criteria, may require Prior Authorization per contract _ _ SUR712.031 Surgical Deactivation of Headache Trigger Sites agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 21/83 MP Criteria: Procedure/service reviewed against Medical Policy 67901 Repair Eyelid Defect Criteria. Submit for predetermination to avoid post-service SUR716.004 Blepharoplasty, Blepharoptosis and Brow Repair _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy 67902 Repair Eyelid Defect Criteria. Submit for predetermination to avoid post-service SUR716.004 Blepharoplasty, Blepharoptosis and Brow Repair _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy 67903 Repair Eyelid Defect Criteria. Submit for predetermination to avoid post-service SUR716.004 Blepharoplasty, Blepharoptosis and Brow Repair _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy 67904 Repair Eyelid Defect Criteria. Submit for predetermination to avoid post-service SUR716.004 Blepharoplasty, Blepharoptosis and Brow Repair _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy 67906 Repair Eyelid Defect Criteria. Submit for predetermination to avoid post-service SUR716.004 Blepharoplasty, Blepharoptosis and Brow Repair _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy 67908 Repair Eyelid Defect Criteria. Submit for predetermination to avoid post-service SUR716.004 Blepharoplasty, Blepharoptosis and Brow Repair _ _ review. Unlisted: Procedure/service not specifically defined or 67999 Revision Of Eyelid _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 68399 Eyelid Lining Surgery _ _ _ _ classified, maybe subject to contract/clinical review. Tear Duct System Unlisted: Procedure/service not specifically defined or 68899 _ _ _ _ Surgery classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy 69090 Pierce Earlobes Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ review. Outer Ear Surgery Unlisted: Procedure/service not specifically defined or 69399 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Nps Surg Dilat Eust 69705 Criteria. Submit for predetermination to avoid post-service SUR706.018 Balloon Dilation of the Eustachian Tube 1/15/2021 _ Tube Uni review. MP Criteria: Procedure/service reviewed against Medical Policy Nps Surg Dilat Eust 69706 Criteria. Submit for predetermination to avoid post-service SUR706.018 Balloon Dilation of the Eustachian Tube 1/15/2021 _ Tube Bi review. MP Criteria: Procedure/service reviewed against Medical Implant Temple Bone 69714 Policy Criteria, may require Prior Authorization per contract SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ W/Stimul agreement. MP Criteria: Procedure/service reviewed against Medical Temple Bne Implnt 69715 Policy Criteria, may require Prior Authorization per contract SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ W/Stimulat agreement. MP Criteria: Procedure/service reviewed against Medical Temple Bone Implant 69717 Policy Criteria, may require Prior Authorization per contract SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ Revision agreement. MP Criteria: Procedure/service reviewed against Medical Revise Temple Bone 69718 Policy Criteria, may require Prior Authorization per contract SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ Implant agreement. Middle Ear Surgery Unlisted: Procedure/service not specifically defined or 69799 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Implant Cochlear 69930 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Device agreement. Inner Ear Surgery Unlisted: Procedure/service not specifically defined or 69949 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 69979 Temporal Bone Surgery _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 76496 Fluoroscopic Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 76497 Ct Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 76498 Mri Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 76499 Radiographic Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Echo Examination Unlisted: Procedure/service not specifically defined or 76999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Radiation Therapy Unlisted: Procedure/service not specifically defined or 77299 _ _ _ _ Planning classified, maybe subject to contract/clinical review. External Radiation Unlisted: Procedure/service not specifically defined or 77399 _ _ _ _ Dosimetry classified, maybe subject to contract/clinical review. Radiation Therapy Unlisted: Procedure/service not specifically defined or 77499 _ _ _ _ Management classified, maybe subject to contract/clinical review. Radium/Radioisotope Unlisted: Procedure/service not specifically defined or 77799 _ _ _ _ Therapy classified, maybe subject to contract/clinical review. Endocrine Nuclear Unlisted: Procedure/service not specifically defined or 78099 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Blood/Lymph Nuclear Unlisted: Procedure/service not specifically defined or 78199 _ _ _ _ Exam classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 78299 Gi Nuclear Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Musculoskeletal Unlisted: Procedure/service not specifically defined or 78399 _ _ _ _ Nuclear Exam classified, maybe subject to contract/clinical review. Cardiovascular Nuclear Unlisted: Procedure/service not specifically defined or 78499 _ _ _ _ Exam classified, maybe subject to contract/clinical review. Respiratory Nuclear Unlisted: Procedure/service not specifically defined or 78599 _ _ _ _ Exam classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 22/83 Nervous System Unlisted: Procedure/service not specifically defined or 78699 _ _ _ _ Nuclear Exam classified, maybe subject to contract/clinical review. Genitourinary Nuclear Unlisted: Procedure/service not specifically defined or 78799 _ _ _ _ Exam classified, maybe subject to contract/clinical review. Nuclear Diagnostic Unlisted: Procedure/service not specifically defined or 78999 _ _ _ _ Exam classified, maybe subject to contract/clinical review. Nuclear Medicine Unlisted: Procedure/service not specifically defined or 79999 _ _ _ _ Therapy classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 80299 Quantitative Assay Drug _ _ _ _ classified, maybe subject to contract/clinical review. Urinalysis Test Unlisted: Procedure/service not specifically defined or 81099 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or Unlisted Molecular 81479 classified, maybe subject to contract/clinical review. May AIM Guidelines _ _ _ Pathology require Prior Authorization per contract agreement. Unlisted: Procedure/service not specifically defined or 81599 Unlisted Maaa AIM Guidelines _ _ _ classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Bone Turnover Markers for Diagnosis and Management of 82523 Collagen Crosslinks to pre-service review. Check EIU policy CPCP028, which is one MED207.116 _ _ Osteoporosis and Diseases Associated with High Bone Turnover of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Novel Biomarkers in Risk Assessment and Management of 83695 Assay Of Lipoprotein(A) to pre-service review. Check EIU policy CPCP028, which is one MED207.008 _ _ Cardiovascular Disease of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Measurement of Phospholipase A2 in the Assessment of 83698 Assay Lipoprotein Pla1 to pre-service review. Check EIU policy CPCP028, which is one MED207.134 _ _ Cardiovascular Risk of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Lipoprotein Bld Hr Novel Biomarkers in Risk Assessment and Management of 83701 to pre-service review. Check EIU policy CPCP028, which is one MED207.008 _ _ Fraction Cardiovascular Disease of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Lipoprotein Bld Quan Novel Biomarkers in Risk Assessment and Management of 83704 to pre-service review. Check EIU policy CPCP028, which is one MED207.008 _ _ Part Cardiovascular Disease of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Lipoprtn Dir Meas Sd Novel Biomarkers in Risk Assessment and Management of 83722 to pre-service review. Check EIU policy CPCP028, which is one MED207.008 _ _ Ldl Chl Cardiovascular Disease of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bone Turnover Markers for Diagnosis and Management of 83937 Assay Of Osteocalcin to pre-service review. Check EIU policy CPCP028, which is one MED207.116 _ _ Osteoporosis and Diseases Associated with High Bone Turnover of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Exhaled Breath Measurement of Exhaled Breath Condensate in the Diagnosis and 83987 to pre-service review. Check EIU policy CPCP028, which is one MED201.024 _ _ Condensate Management of Respiratory Disorders of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Eval Amniotic Fluid Tests for Amniotic Protein to Detect Rupture of Membranes (ROM) 84112 to pre-service review. Check EIU policy CPCP028, which is one OB401.018 _ _ Protein in Pregnancy of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject 84431 Thromboxane Urine to pre-service review. Check EIU policy CPCP028, which is one MED207.148 Measurement of Thromboxane Metabolites in Urine _ _ of our Clinical Payment and Coding Policy (CPCP). Unlisted: Procedure/service not specifically defined or 84999 Clinical Chemistry Test AIM Guidelines _ _ _ classified, maybe subject to contract/clinical review.. Unlisted: Procedure/service not specifically defined or 85999 Hematology Procedure _ _ _ _ classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject 86001 Allergen Specific Igg to pre-service review. Check EIU policy CPCP028, which is one MED206.001 Allergy Management _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Leukocyte Histamine 86343 to pre-service review. Check EIU policy CPCP028, which is one MED206.001 Allergy Management _ _ Release of our Clinical Payment and Coding Policy (CPCP). Unlisted: Procedure/service not specifically defined or 86486 Skin Test Nos Antigen _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 86849 Immunology Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Blood Typing Paternity Non Covered: Procedure/service not covered by the Plan. Not 86910 _ _ _ _ Test subject to pre-service review. Blood Typing Antigen Non Covered: Procedure/service not covered by the Plan. Not 86911 _ _ _ _ System subject to pre-service review. Unlisted: Procedure/service not specifically defined or 86999 Transfusion Procedure _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy 87505 Nfct Agent Detection Gi Criteria. Submit for predetermination to avoid post-service MED207.155 Gastrointestinal Panels _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Iadna-Dna/Rna Probe 87506 Criteria. Submit for predetermination to avoid post-service MED207.155 Gastrointestinal Panels _ _ Tq 6-10 review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 23/83 MP Criteria: Procedure/service reviewed against Medical Policy Iadna-Dna/Rna Probe 87507 Criteria. Submit for predetermination to avoid post-service MED207.155 Gastrointestinal Panels _ _ Tq 12-24 review. Detect Agent Nos Dna Unlisted: Procedure/service not specifically defined or 87797 _ _ _ _ Dir classified, maybe subject to contract/clinical review. Detect Agent Nos Dna Unlisted: Procedure/service not specifically defined or 87798 _ _ _ _ Amp classified, maybe subject to contract/clinical review. Detect Agent Nos Dna Unlisted: Procedure/service not specifically defined or 87799 _ _ _ _ Quant classified, maybe subject to contract/clinical review. Agent Nos Assay Unlisted: Procedure/service not specifically defined or 87899 _ _ _ _ W/Optic classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 87999 Microbiology Procedure _ _ _ _ classified, maybe subject to contract/clinical review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88000 _ _ _ _ Gross subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88005 _ _ _ _ Gross subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88007 _ _ _ _ Gross subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88012 _ _ _ _ Gross subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88014 _ _ _ _ Gross subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88016 _ _ _ _ Gross subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88020 _ _ _ _ Complete subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88025 _ _ _ _ Complete subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88027 _ _ _ _ Complete subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88028 _ _ _ _ Complete subject to pre-service review. Autopsy (Necropsy) Non Covered: Procedure/service not covered by the Plan. Not 88029 _ _ _ _ Complete subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 88036 Limited Autopsy _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 88037 Limited Autopsy _ _ _ _ subject to pre-service review. Forensic Autopsy Non Covered: Procedure/service not covered by the Plan. Not 88040 _ _ _ _ (Necropsy) subject to pre-service review. Coroners Autopsy Non Covered: Procedure/service not covered by the Plan. Not 88045 _ _ _ _ (Necropsy) subject to pre-service review. Necropsy (Autopsy) Non Covered: Procedure/service not covered by the Plan. Not 88099 _ _ _ _ Procedure subject to pre-service review. Cytopathology Unlisted: Procedure/service not specifically defined or 88199 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 88299 Cytogenetic Study _ _ _ _ classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Optical Endomicroscpy 88375 to pre-service review. Check EIU policy CPCP028, which is one MED201.038 Confocal Laser Endomicroscopy (CLE) _ _ Interp of our Clinical Payment and Coding Policy (CPCP). Surgical Pathology Unlisted: Procedure/service not specifically defined or 88399 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 88749 In Vivo Lab Service _ _ _ _ classified, maybe subject to contract/clinical review. Pathology Lab Unlisted: Procedure/service not specifically defined or 89240 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Cryopreservation Non Covered: Procedure/service not covered by the Plan. Not 89258 _ _ _ _ Embryo(S) subject to pre-service review. Cryopreservation Non Covered: Procedure/service not covered by the Plan. Not 89259 _ _ _ _ Sperm subject to pre-service review. Cryopreserve Testicular Non Covered: Procedure/service not covered by the Plan. Not 89335 _ _ _ _ Tiss subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Cryopreservation 89337 Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss _ _ Oocyte(S) review. Non Covered: Procedure/service not covered by the Plan. Not 89342 Storage/Year Embryo(S) _ _ _ _ subject to pre-service review. Storage/Year Non Covered: Procedure/service not covered by the Plan. Not 89343 _ _ _ _ Sperm/Semen subject to pre-service review. Storage/Year Reprod Non Covered: Procedure/service not covered by the Plan. Not 89344 _ _ _ _ Tissue subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 89346 Storage/Year Oocyte(S) _ _ _ _ subject to pre-service review. Unlisted Reprod Med Unlisted: Procedure/service not specifically defined or 89398 _ _ _ _ Lab Proc classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Autism Spectrum Disorders (ASD) PSY301.014 90283 Human Ig Iv Policy Criteria, may require Prior Authorization per contract Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and _ _ RX504.003 agreement. Subcutaneous Ig [SCIG]) MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and 90284 Human Ig Sc Policy Criteria, may require Prior Authorization per contract RX504.003 _ _ Subcutaneous Ig [SCIG]) agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 24/83 MP Criteria: Procedure/service reviewed against Medical 90378 Rsv Mab Im 50Mg Policy Criteria, may require Prior Authorization per contract RX504.009 Respiratory Syncytial Virus (RSV) Immunoprophylaxis _ _ agreement. Unlisted: Procedure/service not specifically defined or 90399 Immune Globulin _ _ _ _ classified, maybe subject to contract/clinical review. Tic-Brn Enceph Vac Non Covered: Procedure/service not covered by the Plan. Not 90626 _ _ 7/1/2021 _ 0.25Ml Im subject to pre-service review. Tic-Brn Enceph Vac Non Covered: Procedure/service not covered by the Plan. Not 90627 _ _ 7/1/2021 _ 0.5Ml Im subject to pre-service review. Flu Vac Pandem Prsrv Non Covered: Procedure/service not covered by the Plan. Not 90666 _ _ _ _ Free Im subject to pre-service review. Iiv Vacc Pandemic Non Covered: Procedure/service not covered by the Plan. Not 90667 _ _ _ _ Adjuvt Im subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 90668 Iiv Vaccine Pandemic Im _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 90671 Pcv15 Vaccine Im _ _ 7/1/2021 _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 90677 Pcv20 Vaccine Im _ _ 7/1/2021 _ subject to pre-service review. Unlisted: Procedure/service not specifically defined or 90749 Vaccine Toxoid _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Tcranial Magn Stim Tx 90867 Policy Criteria, may require Prior Authorization per contract PSY301.015 Repetitive Transcranial Magnetic Stimulation (rTMS) _ _ Plan agreement. MP Criteria: Procedure/service reviewed against Medical Tcranial Magn Stim Tx 90868 Policy Criteria, may require Prior Authorization per contract PSY301.015 Repetitive Transcranial Magnetic Stimulation (rTMS) _ _ Deli agreement. MP Criteria: Procedure/service reviewed against Medical Tcran Magn Stim 90869 Policy Criteria, may require Prior Authorization per contract PSY301.015 Repetitive Transcranial Magnetic Stimulation (rTMS) _ _ Redetemine agreement. PSY301.018 Biofeedback as a Treatment of Chronic Pain PSY301.017 Biofeedback as a Treatment of Fecal Incontinence or Constipation MP Criteria: Procedure/service reviewed against Medical Policy PSY301.019 Biofeedback as a Treatment of Headache Psychophysiological 90875 Criteria. Submit for predetermination to avoid post-service PSY301.016 Biofeedback as a Treatment of Urinary Incontinence _ _ Therapy review. PSY301.007 Biofeedback for Miscellaneous Indications PSY301.011 Neurofeedback MED205.022 Treatment of Tinnitus

PSY301.018 Biofeedback as a Treatment of Chronic Pain PSY301.017 Biofeedback as a Treatment of Fecal Incontinence or Constipation MP Criteria: Procedure/service reviewed against Medical Policy PSY301.019 Biofeedback as a Treatment of Headache Psychophysiological 90876 Criteria. Submit for predetermination to avoid post-service PSY301.016 Biofeedback as a Treatment of Urinary Incontinence _ _ Therapy review. PSY301.007 Biofeedback for Miscellaneous Indications PSY301.011 Neurofeedback MED205.022 Treatment of Tinnitus MP Criteria: Procedure/service reviewed against Medical Policy 90880 Hypnotherapy Criteria. Submit for predetermination to avoid post-service MED201.001 Hypnosis _ _ review. Psy Evaluation Of Non Covered: Procedure/service not covered by the Plan. Not 90885 _ _ _ _ Records subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 90889 Preparation Of Report _ _ _ _ subject to pre-service review. Psychiatric Unlisted: Procedure/service not specifically defined or 90899 _ _ _ _ Service/Therapy classified, maybe subject to contract/clinical review. PSY301.018 Biofeedback as a Treatment of Chronic Pain PSY301.017 Biofeedback as a Treatment of Fecal Incontinence or Constipation MP Criteria: Procedure/service reviewed against Medical Policy PSY301.019 Biofeedback as a Treatment of Headache Biofeedback Train Any 90901 Criteria. Submit for predetermination to avoid post-service PSY301.016 Biofeedback as a Treatment of Urinary Incontinence _ _ Meth review. PSY301.007 Biofeedback for Miscellaneous Indications PSY301.011 Neurofeedback MED205.022 Treatment of Tinnitus MP Criteria: Procedure/service reviewed against Medical Policy PSY301.017 Biofeedback as a Treatment of Fecal Incontinence or Constipation 90912 Bfb Training 1St 15 Min Criteria. Submit for predetermination to avoid post-service 4/1/2021 _ PSY301.016 Biofeedback as a Treatment of Urinary Incontinence review. MP Criteria: Procedure/service reviewed against Medical Policy Bfb Training Ea Addl 15 PSY301.017 Biofeedback as a Treatment of Fecal Incontinence or Constipation 90913 Criteria. Submit for predetermination to avoid post-service 4/1/2021 _ Min PSY301.016 Biofeedback as a Treatment of Urinary Incontinence review. Unlisted: Procedure/service not specifically defined or 90999 Dialysis Procedure _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Gastroesophageal 91034 Criteria. Submit for predetermination to avoid post-service MED201.005 Esophageal pH Monitoring _ _ Reflux Test review. MP Criteria: Procedure/service reviewed against Medical Policy G-Esoph Reflx Tst 91035 Criteria. Submit for predetermination to avoid post-service MED201.005 Esophageal pH Monitoring _ _ W/Electrod review. MP Criteria: Procedure/service reviewed against Medical Policy Esoph Imped Function 91037 Criteria. Submit for predetermination to avoid post-service MED201.005 Esophageal pH Monitoring _ _ Test review. MP Criteria: Procedure/service reviewed against Medical Policy Esoph Imped Funct Test 91038 Criteria. Submit for predetermination to avoid post-service MED201.005 Esophageal pH Monitoring _ _ > 1Hr review. Breath EIU: Procedure/service not reimbursed by the Plan. Not subject 91065 Hydrogen/Methane to pre-service review. Check EIU policy CPCP028, which is one MED207.161 Hydrogen or Methane Breath Testing _ _ Test of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 25/83 MP Criteria: Procedure/service reviewed against Medical Policy Gi Tract Capsule Wireless Capsule Endoscopy (WCE) To Diagnose Disorders of The 91110 Criteria. Submit for predetermination to avoid post-service RAD601.042 _ _ Endoscopy Small Bowel, Esophagus, And Colon review. EIU: Procedure/service not reimbursed by the Plan. Not subject Esophageal Capsule Wireless Capsule Endoscopy (WCE) To Diagnose Disorders of The 91111 to pre-service review. Check EIU policy CPCP028, which is one RAD601.042 _ _ Endoscopy Small Bowel, Esophagus, And Colon of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Gi Wireless Capsule 91112 to pre-service review. Check EIU policy CPCP028, which is one MED201.017 Gastrointestinal (GI) Motility Measurement _ _ Measure of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject 91132 Electrogastrography to pre-service review. Check EIU policy CPCP028, which is one MED201.017 Gastrointestinal (GI) Motility Measurement _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Electrogastrography 91133 to pre-service review. Check EIU policy CPCP028, which is one MED201.017 Gastrointestinal (GI) Motility Measurement _ _ W/Test of our Clinical Payment and Coding Policy (CPCP). Gastroenterology Unlisted: Procedure/service not specifically defined or 91299 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Determine Refractive Non Covered: Procedure/service not covered by the Plan. Not 92015 _ _ _ _ State subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Cmptr Ophth Dx Img 92132 to pre-service review. Check EIU policy CPCP028, which is one OTH903.021 Optical Coherence Tomography of the Anterior Eye Segment _ _ Ant Segmt of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Corneal Hysteresis 92145 to pre-service review. Check EIU policy CPCP028, which is one OTH903.031 Corneal Hysteresis _ _ Deter of our Clinical Payment and Coding Policy (CPCP). Fit Spectacles Non Covered: Procedure/service not covered by the Plan. Not 92340 _ _ _ _ Monofocal subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 92341 Fit Spectacles Bifocal _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 92342 Fit Spectacles Multifocal _ _ _ _ subject to pre-service review. Fit Spectacles Single Non Covered: Procedure/service not covered by the Plan. Not 92354 _ _ _ _ System subject to pre-service review. Fit Spectacles Non Covered: Procedure/service not covered by the Plan. Not 92355 _ _ _ _ Compound Lens subject to pre-service review. Repair & Adjust Non Covered: Procedure/service not covered by the Plan. Not 92370 _ _ _ _ Spectacles subject to pre-service review. Eye Service Or Unlisted: Procedure/service not specifically defined or 92499 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Rhinomanometry, Acoustic Rhinometry, Optical Rhinometry and 92512 Nasal Function Studies to pre-service review. Check EIU policy CPCP028, which is one MED204.004 _ _ Acoustic Pharyngometry of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject 92517 Vemp Test I&R Cervical to pre-service review. Check EIU policy CPCP028, which is one MED201.047 Vestibular Function Testing 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject 92518 Vemp Test I&R Ocular to pre-service review. Check EIU policy CPCP028, which is one MED201.047 Vestibular Function Testing 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Vemp Tst I&R 92519 to pre-service review. Check EIU policy CPCP028, which is one MED201.047 Vestibular Function Testing 5/15/2021 _ Cervical&Ocular of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject 92548 Cdp-Sot 6 Cond W/I&R to pre-service review. Check EIU policy CPCP028, which is one MED205.026 Dynamic Posturography _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cdp-Sot 6 Cond W/I&R 92549 to pre-service review. Check EIU policy CPCP028, which is one MED205.026 Dynamic Posturography _ _ Mct&Adt of our Clinical Payment and Coding Policy (CPCP). Unlisted: Procedure/service not specifically defined or 92700 Ent Procedure/Service _ _ _ _ classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Art Pressure Waveform 93050 to pre-service review. Check EIU policy CPCP028, which is one MED202.070 Non-Invasive Measurement of Central Blood Pressure (cBP) _ _ Analys of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Remote 30 Day Ecg 93228 Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and _ _ Rev/Report review. Intracardiac Ischemia Detection Systems) MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Remote 30 Day Ecg 93229 Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and _ _ Tech Supp review. Intracardiac Ischemia Detection Systems) MP Criteria: Procedure/service reviewed against Medical Policy Rem Mntr Wrls P-Art Cardiac Hemodynamic Monitoring for the Management of Heart 93264 Criteria. Submit for predetermination to avoid post-service MED202.058 _ _ Prs Snr Failure in the Outpatient Setting review. MP Criteria: Procedure/service reviewed against Medical Policy Transcath Closure Of 93580 Criteria. Submit for predetermination to avoid post-service SUR707.024 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects _ _ Asd review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 26/83 MP Criteria: Procedure/service reviewed against Medical Policy 93660 Tilt Table Evaluation Criteria. Submit for predetermination to avoid post-service MED202.048 Tilt Table Testing _ _ review. EIU: Procedure/service not reimbursed by the Plan. Not subject Bis Xtracell Fluid Bioimpedance Devices for Detection and Management of 93702 to pre-service review. Check EIU policy CPCP028, which is one MED201.036 _ _ Analysis Lymphedema of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Temperature Gradient 93740 to pre-service review. Check EIU policy CPCP028, which is one RAD601.014 Thermography _ _ Studies of our Clinical Payment and Coding Policy (CPCP). Cardiovascular Unlisted: Procedure/service not specifically defined or 93799 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Carotid Intima Ultrasonographic Measurement of Carotid Intima-Medial Thickness 93895 Criteria. Submit for predetermination to avoid post-service RAD602.018 _ _ Atheroma Eval (CIMT) as an Assessment of Subclinical Atherosclerosis review. Noninvas Vasc Dx Study Unlisted: Procedure/service not specifically defined or 93998 _ _ _ _ Proc classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Patient Recorded 94014 to pre-service review. Check EIU policy CPCP028, which is one DME101.040 Home Spirometry _ _ Spirometry of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Patient Recorded 94015 to pre-service review. Check EIU policy CPCP028, which is one DME101.040 Home Spirometry _ _ Spirometry of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Review Patient 94016 to pre-service review. Check EIU policy CPCP028, which is one DME101.040 Home Spirometry _ _ Spirometry of our Clinical Payment and Coding Policy (CPCP). Non Covered: Procedure/service not covered by the Plan. Not 94452 Hast W/Report _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 94453 Hast W/Oxygen Titrate _ _ _ _ subject to pre-service review. Pulmonary Unlisted: Procedure/service not specifically defined or 94799 _ _ _ _ Service/Procedure classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject MED206.001 Allergy Management 95060 Eye Allergy Tests to pre-service review. Check EIU policy CPCP028, which is one _ _ PSY301.014 Autism Spectrum Disorders (ASD) of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject MED206.001 Allergy Management 95065 Nose Allergy Test to pre-service review. Check EIU policy CPCP028, which is one _ _ PSY301.014 Autism Spectrum Disorders (ASD) of our Clinical Payment and Coding Policy (CPCP). Allergy Immunology Unlisted: Procedure/service not specifically defined or 95199 _ _ _ _ Services classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy 95803 Actigraphy Testing Criteria. Submit for predetermination to avoid post-service MED201.048 Actigraphy _ _ review. EIU: Procedure/service not reimbursed by the Plan. Not subject Motor &/ Sens Nrve 95905 to pre-service review. Check EIU policy CPCP028, which is one MED205.033 Automated Point-of-Care Nerve Conduction Testing _ _ Cndj Test of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Electrode Stimulation MED205.011 Intraoperative Neurophysiologic Monitoring (IONM) 95961 Criteria. Submit for predetermination to avoid post-service _ _ Brain MED205.009 Topographic Brain Mapping (Quantitative Electroencephalography) review. MP Criteria: Procedure/service reviewed against Medical Policy Electrode Stim Brain MED205.011 Intraoperative Neurophysiologic Monitoring (IONM) 95962 Criteria. Submit for predetermination to avoid post-service _ _ Add-On MED205.009 Topographic Brain Mapping (Quantitative Electroencephalography) review. MP Criteria: Procedure/service reviewed against Medical Policy Autism Spectrum Disorders (ASD) PSY301.014 95965 Meg Spontaneous Criteria. Submit for predetermination to avoid post-service Magnetoencephalography (MEG) and Magnetic Source Imaging _ _ RAD601.038 review. (MSI) MP Criteria: Procedure/service reviewed against Medical Policy Autism Spectrum Disorders (ASD) PSY301.014 95966 Meg Evoked Single Criteria. Submit for predetermination to avoid post-service Magnetoencephalography (MEG) and Magnetic Source Imaging _ _ RAD601.038 review. (MSI) MP Criteria: Procedure/service reviewed against Medical Policy Autism Spectrum Disorders (ASD) PSY301.014 95967 Meg Evoked Each Addl Criteria. Submit for predetermination to avoid post-service Magnetoencephalography (MEG) and Magnetic Source Imaging _ _ RAD601.038 review. (MSI) MP Criteria: Procedure/service reviewed against Medical 95980 Io Anal Gast N-Stim Init Policy Criteria, may require Prior Authorization per contract SUR709.031 Gastric Electrical Stimulation (GES) _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy Io Anal Gast N-Stim 95981 Criteria. Submit for predetermination to avoid post-service SUR709.031 Gastric Electrical Stimulation (GES) _ _ Subsq review. MP Criteria: Procedure/service reviewed against Medical Policy Io Ga N-Stim Subsq 95982 Criteria. Submit for predetermination to avoid post-service SUR709.031 Gastric Electrical Stimulation (GES) _ _ W/Reprog review. Unlisted: Procedure/service not specifically defined or 95999 Neurological Procedure _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Motion Analysis 96000 Criteria. Submit for predetermination to avoid post-service THE803.009 Gait Analysis _ _ Video/3D review. MP Criteria: Procedure/service reviewed against Medical Policy Motion Test W/Ft Press 96001 Criteria. Submit for predetermination to avoid post-service THE803.009 Gait Analysis _ _ Meas review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 27/83 MP Criteria: Procedure/service reviewed against Medical Policy Gait Analysis THE803.009 96002 Dynamic Surface Emg Criteria. Submit for predetermination to avoid post-service Surface Scanning Electromyography (EMG) (SEMG), Paraspinal _ _ MED205.006 review. Surface EMG, and Spinoscopy MP Criteria: Procedure/service reviewed against Medical Policy 96003 Dynamic Fine Wire Emg Criteria. Submit for predetermination to avoid post-service THE803.009 Gait Analysis _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Gait Analysis Phys Review Of Motion THE803.009 96004 Criteria. Submit for predetermination to avoid post-service Surface Scanning Electromyography (EMG) (SEMG), Paraspinal _ _ Tests MED205.006 review. Surface EMG, and Spinoscopy Ther/Prop/Diag Inj/Inf Unlisted: Procedure/service not specifically defined or 96379 _ _ _ _ Proc classified, maybe subject to contract/clinical review. Chemotherapy Unlisted: Procedure/service not specifically defined or 96549 _ _ _ _ Unspecified classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Photodynamic Tx Addl Oncologic Applications of Photodynamic Therapy, Including Barrett 96571 Criteria. Submit for predetermination to avoid post-service THE801.029 _ _ 15 Min Esophagus review. MP Criteria: Procedure/service reviewed against Medical Policy Photochemotherapy 96912 Criteria. Submit for predetermination to avoid post-service THE801.033 Phototherapy for Dermatologic Conditions _ _ With Uv-A review. MP Criteria: Procedure/service reviewed against Medical Policy Photochemotherapy Uv- 96913 Criteria. Submit for predetermination to avoid post-service THE801.033 Phototherapy for Dermatologic Conditions _ _ A Or B review. Dermatological Unlisted: Procedure/service not specifically defined or 96999 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject THE803.008 Non Covered Physical Therapy Services Diathermy Eg 97024 to pre-service review. Check EIU policy CPCP028, which is one THE803.010 Physical Therapy (PT) and Occupational Therapy (OT) Services _ 6/20/2021 Microwave of our Clinical Payment and Coding Policy (CPCP). SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) Physical Therapy Unlisted: Procedure/service not specifically defined or 97039 _ _ _ _ Treatment classified, maybe subject to contract/clinical review. Physical Medicine Unlisted: Procedure/service not specifically defined or 97139 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Athletic Trn Eval Low Non Covered: Procedure/service not covered by the Plan. Not 97169 _ _ _ _ Cmplx subject to pre-service review. Athletic Trn Eval Mod Non Covered: Procedure/service not covered by the Plan. Not 97170 _ _ _ _ Cmplx subject to pre-service review. Athletic Trn Eval High Non Covered: Procedure/service not covered by the Plan. Not 97171 _ _ _ _ Cmplx subject to pre-service review. Athletic Trn Re-Eval Non Covered: Procedure/service not covered by the Plan. Not 97172 _ _ _ _ Plan Cr subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy PSY301.014 Autism Spectrum Disorders (ASD) 97533 Sensory Integration Criteria. Submit for predetermination to avoid post-service _ _ THE803.020 Sensory Integration Therapy and Auditory Integration Therapy review. EIU: Procedure/service not reimbursed by the Plan. Not subject Low Frequency Non- 97610 to pre-service review. Check EIU policy CPCP028, which is one DME101.044 Ultrasound Wound Therapy _ _ Thermal Us of our Clinical Payment and Coding Policy (CPCP). Physical Medicine Unlisted: Procedure/service not specifically defined or 97799 _ _ _ _ Procedure classified, maybe subject to contract/clinical review. Acupunct W/O Stimul Non Covered: Procedure/service not covered by the Plan. Not 97810 _ _ _ _ 15 Min subject to pre-service review. Acupunct W/O Stimul Non Covered: Procedure/service not covered by the Plan. Not 97811 _ _ _ _ Addl 15M subject to pre-service review. Acupunct W/Stimul 15 Non Covered: Procedure/service not covered by the Plan. Not 97813 _ _ _ _ Min subject to pre-service review. Acupunct W/Stimul Non Covered: Procedure/service not covered by the Plan. Not 97814 _ _ _ _ Addl 15M subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 99024 Postop Follow-Up Visit _ _ _ _ subject to pre-service review. In-Hospital On Call Non Covered: Procedure/service not covered by the Plan. Not 99026 _ _ _ _ Service subject to pre-service review. Out-Of-Hosp On Call Non Covered: Procedure/service not covered by the Plan. Not 99027 _ _ _ _ Service subject to pre-service review. Medical Services After Unlisted: Procedure/service not specifically defined or 99050 _ _ _ _ Hrs classified, maybe subject to contract/clinical review. Med Service Out Of Unlisted: Procedure/service not specifically defined or 99056 _ _ _ _ Office classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or 99058 Office Emergency Care _ _ _ _ classified, maybe subject to contract/clinical review. Special Supplies Unlisted: Procedure/service not specifically defined or 99070 _ _ _ _ Phys/Qhp classified, maybe subject to contract/clinical review. Patient Education Non Covered: Procedure/service not covered by the Plan. Not 99071 _ _ _ _ Materials subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 99075 Medical Testimony _ _ _ _ subject to pre-service review. Unlisted: Procedure/service not specifically defined or 99078 Group Health Education _ _ _ _ classified, maybe subject to contract/clinical review. Special Reports Or Non Covered: Procedure/service not covered by the Plan. Not 99080 _ _ _ _ Forms subject to pre-service review. Unusual Physician Unlisted: Procedure/service not specifically defined or 99082 _ _ _ _ Travel classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Hyperbaric Oxygen 99183 Policy Criteria, may require Prior Authorization per contract PSY301.014 Autism Spectrum Disorders (ASD) _ _ Therapy agreement. Special Unlisted: Procedure/service not specifically defined or 99199 _ _ _ _ Service/Proc/Report classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 28/83 Unlisted Preventive Unlisted: Procedure/service not specifically defined or 99429 _ _ _ _ Service classified, maybe subject to contract/clinical review. Chrnc Care Mgmt Svc Non Covered: Procedure/service not covered by the Plan. Not 99439 _ _ 1/1/2021 _ Ea Addl subject to pre-service review. Ntrprof Ph1/Ntrnet/Ehr Non Covered: Procedure/service not covered by the Plan. Not 99446 _ _ _ _ 5-9 subject to pre-service review. Ntrprof Ph1/Ntrnet/Ehr Non Covered: Procedure/service not covered by the Plan. Not 99447 _ _ _ _ 11-19 subject to pre-service review. Ntrprof Ph1/Ntrnet/Ehr Non Covered: Procedure/service not covered by the Plan. Not 99448 _ _ _ _ 21-29 subject to pre-service review. Ntrprof Ph1/Ntrnet/Ehr Non Covered: Procedure/service not covered by the Plan. Not 99449 _ _ _ _ 31/> subject to pre-service review. Basic Life Disability Non Covered: Procedure/service not covered by the Plan. Not 99450 _ _ _ _ Exam subject to pre-service review. Ntrprof Ph1/Ntrnet/Ehr Non Covered: Procedure/service not covered by the Plan. Not 99451 _ _ _ _ 5/> subject to pre-service review. Ntrprof Ph1/Ntrnet/Ehr Non Covered: Procedure/service not covered by the Plan. Not 99452 _ _ _ _ Rfrl subject to pre-service review. Rem Mntr Physiol Non Covered: Procedure/service not covered by the Plan. Not 99453 _ _ _ _ Param Setup subject to pre-service review. Rem Mntr Physiol Non Covered: Procedure/service not covered by the Plan. Not 99454 _ _ _ _ Param Dev subject to pre-service review. Work Related Disability Non Covered: Procedure/service not covered by the Plan. Not 99455 _ _ _ _ Exam subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not 99456 Disability Examination _ _ _ _ subject to pre-service review. Rem Physiol Mntr 1St Non Covered: Procedure/service not covered by the Plan. Not 99457 _ _ _ _ 20 Min subject to pre-service review. Rem Physiol Mntr Ea Non Covered: Procedure/service not covered by the Plan. Not 99458 _ _ _ _ Addl 19 subject to pre-service review. Cplx Chrnc Care 1St 60 Non Covered: Procedure/service not covered by the Plan. Not 99487 _ _ _ _ Min subject to pre-service review. Cplx Chrnc Care Ea Addl Non Covered: Procedure/service not covered by the Plan. Not 99489 _ _ _ _ 29 subject to pre-service review. Chrnc Care Mgmt Svc Non Covered: Procedure/service not covered by the Plan. Not 99490 _ _ _ _ 1St 19 subject to pre-service review. Chrnc Care Mgmt Svc Non Covered: Procedure/service not covered by the Plan. Not 99491 _ _ _ _ 30 Min subject to pre-service review. Unlisted: Procedure/service not specifically defined or 99499 Unlisted E&M Service _ _ _ _ classified, maybe subject to contract/clinical review. Home Visit Day Life Non Covered: Procedure/service not covered by the Plan. Not 99509 _ _ _ _ Activity subject to pre-service review. Unlisted: Procedure/service not specifically defined or 99600 Home Visit Nos _ _ _ _ classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Lpoprtn Bld W/5 Maj Novel Biomarkers in Risk Assessment and Management of 0052U to pre-service review. Check EIU policy CPCP028, which is one MED207.008 _ _ Classes Cardiovascular Disease of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bone Srgry Cmptr Fluor 0054T to pre-service review. Check EIU policy CPCP028, which is one SUR705.023 Computer-Assisted Navigation for Orthopedic Procedures _ _ Image of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bone Srgry Cmptr 0055T to pre-service review. Check EIU policy CPCP028, which is one SUR705.023 Computer-Assisted Navigation for Orthopedic Procedures _ _ Ct/Mri Imag of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Ai Sle Igg&Igm Alys 80 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus 0062U to pre-service review. Check EIU policy CPCP028, which is one MED207.159 _ _ Bmrk and Other Connective Tissue Diseases of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Neuro Autism 32 0063U to pre-service review. Check EIU policy CPCP028, which is one PSY301.014 Autism Spectrum Disorders (ASD) _ _ Amines Alg of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Pamg-1 Ia Cervico-Vag Tests for Amniotic Protein to Detect Rupture of Membranes (ROM) 0066U to pre-service review. Check EIU policy CPCP028, which is one OB401.018 _ _ Fluid in Pregnancy of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Perq Stent/Chest Vert 0075T Criteria. Submit for predetermination to avoid post-service SUR701.041 Endovascular Therapies for Extracranial Vertebral Artery Disease _ _ Art review. MP Criteria: Procedure/service reviewed against Medical Policy S&I Stent/Chest Vert 0076T Criteria. Submit for predetermination to avoid post-service SUR701.041 Endovascular Therapies for Extracranial Vertebral Artery Disease _ _ Art review. MP Criteria: Procedure/service reviewed against Medical Policy 0097U Gi Pathogen 22 Targets Criteria. Submit for predetermination to avoid post-service MED207.155 Gastrointestinal Panels _ _ review. EIU: Procedure/service not reimbursed by the Plan. Not subject Prosth Retina 0100T to pre-service review. Check EIU policy CPCP028, which is one SUR713.026 Retinal Prosthesis _ _ Receive&Gen of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Extracorp Shockwv Tx Extracorporeal Shock Wave Therapy for Musculoskeletal 0101T to pre-service review. Check EIU policy CPCP028, which is one SUR705.018 _ _ Hi Enrg Indications and Soft Tissue Injuries of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 29/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Extracorp Shockwv Tx Extracorporeal Shock Wave Therapy for Musculoskeletal 0102T to pre-service review. Check EIU policy CPCP028, which is one SUR705.018 _ _ Anesth Indications and Soft Tissue Injuries of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Touch Quant Sensory 0106T to pre-service review. Check EIU policy CPCP028, which is one MED205.030 Quantitative Sensory Testing _ _ Test of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Gstr Emptg 7 Timed 0106U to pre-service review. Check EIU policy CPCP028, which is one MED201.017 Gastrointestinal (GI) Motility Measurement _ _ Brth Spec of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Vibrate Quant Sensory 0107T to pre-service review. Check EIU policy CPCP028, which is one MED205.030 Quantitative Sensory Testing _ _ Test of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cool Quant Sensory 0108T to pre-service review. Check EIU policy CPCP028, which is one MED205.030 Quantitative Sensory Testing _ _ Test of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Heat Quant Sensory 0109T to pre-service review. Check EIU policy CPCP028, which is one MED205.030 Quantitative Sensory Testing _ _ Test of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject 0110T Nos Quant Sensory Test to pre-service review. Check EIU policy CPCP028, which is one MED205.030 Quantitative Sensory Testing _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Rbc Membranes Fatty 0111T to pre-service review. Check EIU policy CPCP028, which is one N/A N/A _ 12/31/2020 Acids of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Neuro Austm Meas 6 C 0139U to pre-service review. Check EIU policy CPCP028, which is one PSY301.014 Autism Spectrum Disorders (ASD) _ _ Metablt of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Exc Rectal Tumor 0184T Criteria. Submit for predetermination to avoid post-service SUR701.040 Transanal Endoscopic Microsurgery _ _ Endoscopic review. MP Criteria: Procedure/service reviewed against Medical Policy Insert Ant Segment 0191T Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma 5/1/2021 _ Drain Int review. EIU: Procedure/service not reimbursed by the Plan. Not subject Ocular Blood Flow 0198T to pre-service review. Check EIU policy CPCP028, which is one OTH903.022 Ophthalmologic Techniques For Evaluating Glaucoma _ _ Measure of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Perq Sacral Augmt 0200T Criteria. Submit for predetermination to avoid post-service RAD601.056 Percutaneous Vertebroplasty and Sacroplasty _ _ Unilat Inj review. MP Criteria: Procedure/service reviewed against Medical Policy Perq Sacral Augmt Bilat 0201T Criteria. Submit for predetermination to avoid post-service RAD601.056 Percutaneous Vertebroplasty and Sacroplasty _ _ Inj review. EIU: Procedure/service not reimbursed by the Plan. Not subject Post Vert Arthrplst 1 0202T to pre-service review. Check EIU policy CPCP028, which is one SUR712.034 Facet Arthroplasty _ _ Lumbar of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Clear Eyelid Gland 0207T to pre-service review. Check EIU policy CPCP028, which is one OTH903.025 Eyelid Thermal Pulsation _ _ W/Heat of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Njx Paravert W/Us 0213T Policy Criteria, may require Prior Authorization per contract SUR702.015 Facet Joint Injections _ _ Cer/Thor agreement. MP Criteria: Procedure/service reviewed against Medical Njx Paravert W/Us 0214T Policy Criteria, may require Prior Authorization per contract SUR702.015 Facet Joint Injections _ _ Cer/Thor agreement. MP Criteria: Procedure/service reviewed against Medical Njx Paravert W/Us 0216T Policy Criteria, may require Prior Authorization per contract SUR702.015 Facet Joint Injections _ _ Lumb/Sac agreement. MP Criteria: Procedure/service reviewed against Medical Njx Paravert W/Us 0217T Policy Criteria, may require Prior Authorization per contract SUR702.015 Facet Joint Injections _ _ Lumb/Sac agreement. EIU: Procedure/service not reimbursed by the Plan. Not subject Plmt Post Facet Implt 0219T to pre-service review. Check EIU policy CPCP028, which is one SUR712.032 Isolated Facet Joint Fusion _ _ Cerv of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Plmt Post Facet Implt 0220T to pre-service review. Check EIU policy CPCP028, which is one SUR712.032 Isolated Facet Joint Fusion _ _ Thor of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Plmt Post Facet Implt 0221T to pre-service review. Check EIU policy CPCP028, which is one SUR712.032 Isolated Facet Joint Fusion _ _ Lumb of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 30/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Plmt Post Facet Implt 0222T to pre-service review. Check EIU policy CPCP028, which is one SUR712.032 Isolated Facet Joint Fusion _ _ Addl of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Orthopedic Applications of Platelet-Rich Plasma RX501.101 0232T Njx Platelet Plasma to pre-service review. Check EIU policy CPCP028, which is one Recombinant and Autologous Platelet-Derived Growth Factors for _ _ RX501.034 of our Clinical Payment and Coding Policy (CPCP). Wound Healing and Other Non-Orthopedic Conditions MP Criteria: Procedure/service reviewed against Medical Policy Insert Aqueous Drain 0253T Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ Device review. EIU: Procedure/service not reimbursed by the Plan. Not subject Im B1 Mrw Cel Ther SUR703.051 Orthopedic Applications of Stem-Cell Therapy 0263T to pre-service review. Check EIU policy CPCP028, which is one _ _ Cmpl SUR703.048 Stem Cell Therapy for Peripheral Arterial Disease (PAD) of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Im B1 Mrw Cel Ther Xcl SUR703.051 Orthopedic Applications of Stem-Cell Therapy 0264T to pre-service review. Check EIU policy CPCP028, which is one _ _ Hrvst SUR703.048 Stem Cell Therapy for Peripheral Arterial Disease (PAD) of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Im B1 Mrw Cel Ther SUR703.051 Orthopedic Applications of Stem-Cell Therapy 0265T to pre-service review. Check EIU policy CPCP028, which is one _ _ Hrvst Onl SUR703.048 Stem Cell Therapy for Peripheral Arterial Disease (PAD) of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Transcutaneous Electrical Stimulation (TENS) and Transcutaneous 0278T Tempr to pre-service review. Check EIU policy CPCP028, which is one MED201.040 _ _ Electrical Modulation Pain Reprocessing (TEMPR) of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Insj Ocular Telescope 0308T Criteria. Submit for predetermination to avoid post-service SUR713.025 Intraocular Lens (IOLs) and Implantable Miniature Telescope (IMT) _ _ Prosth review. MP Criteria: Procedure/service reviewed against Medical 0312T Laps Impltj Nstim Vagus Policy Criteria, may require Prior Authorization per contract SUR701.039 Vagus Nerve Blocking Therapy for Treatment of Obesity 2/15/2021 _ agreement. MP Criteria: Procedure/service reviewed against Medical Laps Rmvl Nstim Array 0313T Policy Criteria, may require Prior Authorization per contract SUR701.039 Vagus Nerve Blocking Therapy for Treatment of Obesity 2/15/2021 _ Vagus agreement. MP Criteria: Procedure/service reviewed against Medical Laps Rmvl Vgl Arry&Pls 0314T Policy Criteria, may require Prior Authorization per contract SUR701.039 Vagus Nerve Blocking Therapy for Treatment of Obesity 2/15/2021 _ Gen agreement. MP Criteria: Procedure/service reviewed against Medical Rmvl Vagus Nerve Pls 0315T Policy Criteria, may require Prior Authorization per contract SUR701.039 Vagus Nerve Blocking Therapy for Treatment of Obesity _ _ Gen agreement. MP Criteria: Procedure/service reviewed against Medical Replc Vagus Nerve Pls 0316T Policy Criteria, may require Prior Authorization per contract SUR701.039 Vagus Nerve Blocking Therapy for Treatment of Obesity _ _ Gen agreement. MP Criteria: Procedure/service reviewed against Medical Elec Alys Vagus Nrv Pls 0317T Policy Criteria, may require Prior Authorization per contract SUR701.039 Vagus Nerve Blocking Therapy for Treatment of Obesity 2/15/2021 _ Gen agreement. EIU: Procedure/service not reimbursed by the Plan. Not subject Tear Film Img Uni/Bi 0330T to pre-service review. Check EIU policy CPCP028, which is one OTH903.025 Eyelid Thermal Pulsation _ _ W/I&R of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Myocardial Sympathetic Innervation Imaging in Patients With 0331T Heart Symp Image Plnr Criteria. Submit for predetermination to avoid post-service RAD604.012 4/1/2021 _ Heart Failure review. MP Criteria: Procedure/service reviewed against Medical Policy Heart Symp Image Plnr Myocardial Sympathetic Innervation Imaging in Patients With 0332T Criteria. Submit for predetermination to avoid post-service RAD604.012 _ _ Spect Heart Failure review. EIU: Procedure/service not reimbursed by the Plan. Not subject 0335T Insj Sinus Tarsi Implant to pre-service review. Check EIU policy CPCP028, which is one SUR705.027 Subtalar Arthroereisis (STA) _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Trnscth Renal Symp Radiofrequency Ablation of the Renal Sympathetic Nerves as a 0338T to pre-service review. Check EIU policy CPCP028, which is one SUR701.030 _ _ Denrv Unl Treatment for Resistant Hypertension of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Trnscth Renal Symp Radiofrequency Ablation of the Renal Sympathetic Nerves as a 0339T to pre-service review. Check EIU policy CPCP028, which is one SUR701.030 _ _ Denrv Bil Treatment for Resistant Hypertension of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Radiostereometric Analysis for Assessment of Orthopedic Implant 0347T Ins Bone Device For Rsa to pre-service review. Check EIU policy CPCP028, which is one RAD601.054 _ _ Position of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Radiostereometric Analysis for Assessment of Orthopedic Implant 0348T Rsa Spine Exam to pre-service review. Check EIU policy CPCP028, which is one RAD601.054 _ _ Position of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Radiostereometric Analysis for Assessment of Orthopedic Implant 0349T Rsa Upper Extr Exam to pre-service review. Check EIU policy CPCP028, which is one RAD601.054 _ _ Position of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Radiostereometric Analysis for Assessment of Orthopedic Implant 0350T Rsa Lower Extr Exam to pre-service review. Check EIU policy CPCP028, which is one RAD601.054 _ _ Position of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 31/83 MP Criteria: Procedure/service reviewed against Medical Policy Oct Brst/Node I&R Per 0352T Criteria. Submit for predetermination to avoid post-service RAD601.053 Optical Coherence Tomography of the Breast _ _ Spec review. MP Criteria: Procedure/service reviewed against Medical Policy Oct Breast Surg Cavity 0354T Criteria. Submit for predetermination to avoid post-service RAD601.053 Optical Coherence Tomography of the Breast _ _ I&R review. EIU: Procedure/service not reimbursed by the Plan. Not subject Gi Tract Capsule Wireless Capsule Endoscopy (WCE) To Diagnose Disorders of The 0355T to pre-service review. Check EIU policy CPCP028, which is one RAD601.042 _ _ Endoscopy Small Bowel, Esophagus, And Colon of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Insrt Drug Device For SUR713.035 Drug-Eluding Intracanalicular Punctal Plugs and Ocular Inserts 0356T Criteria. Submit for predetermination to avoid post-service _ _ Iop OTH903.024 Intravitreal, Punctum and Intracameral Implants review. EIU: Procedure/service not reimbursed by the Plan. Not subject Whole Body Composition Analysis using Dual X-Ray Absorptiometry 0358T Bia Whole Body to pre-service review. Check EIU policy CPCP028, which is one RAD601.045 _ _ (DXA) or Bioelectrical Impedance Analysis (BIA) of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Insert Ant Segment 0376T Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ Drain Int review. EIU: Procedure/service not reimbursed by the Plan. Not subject Visual Field Assmnt 0378T to pre-service review. Check EIU policy CPCP028, which is one MED201.044 Home-Based Monitoring of Visual Field _ _ Rev/Rprt of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Vis Field Assmnt Tech 0379T to pre-service review. Check EIU policy CPCP028, which is one MED201.044 Home-Based Monitoring of Visual Field _ _ Suppt of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Intraop Kinetic Balnce 0396T to pre-service review. Check EIU policy CPCP028, which is one N/A N/A _ 12/31/2020 Sensr of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Ercp W/Optical 0397T to pre-service review. Check EIU policy CPCP028, which is one MED201.038 Confocal Laser Endomicroscopy (CLE) _ _ Endomicroscpy of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy 0398T Mrgfus Strtctc Les Abltj Criteria. Submit for predetermination to avoid post-service SUR701.022 Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Insj/Rplc Cardiac Modulj 0408T Criteria. Submit for predetermination to avoid post-service MED202.068 Cardiac Contractility Modulation (CCM) Device _ _ Sys review. MP Criteria: Procedure/service reviewed against Medical Policy Waterjet Prostate Abltj 0421T Criteria. Submit for predetermination to avoid post-service SUR710.024 Aquablation of the Prostate _ _ Cmpl review. MP Criteria: Procedure/service reviewed against Medical Policy Tactile Breast Img 0422T Criteria. Submit for predetermination to avoid post-service RAD602.019 Elastography _ _ Uni/Bi review. EIU: Procedure/service not reimbursed by the Plan. Not subject Assay Secretory Type Ii Measurement of Phospholipase A2 in the Assessment of 0423T to pre-service review. Check EIU policy CPCP028, which is one MED207.134 _ _ Pla1 Cardiovascular Risk of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Insj/Rplc Nstim Apnea 0424T Criteria. Submit for predetermination to avoid post-service SUR701.042 Phrenic Nerve Stimulation for Central Sleep Apnea _ _ Compl review. MP Criteria: Procedure/service reviewed against Medical Policy 0434T Interro Eval Npgs Apnea Criteria. Submit for predetermination to avoid post-service SUR701.042 Phrenic Nerve Stimulation for Central Sleep Apnea _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Abltj Perc Lxtr/Perph Percutaneous Image-Guided Nerve Cryoablation for Phantom Limb 0441T Criteria. Submit for predetermination to avoid post-service SUR701.035 _ _ Nrv Pain (PLP) review. MP Criteria: Procedure/service reviewed against Medical Policy Percutaneous Image-Guided Nerve Cryoablation for Phantom Limb 0442T Abltj Perc Plex/Trncl Nrv Criteria. Submit for predetermination to avoid post-service SUR701.035 _ _ Pain (PLP) review. EIU: Procedure/service not reimbursed by the Plan. Not subject 0th Plmt Drug Elut Oc 0444T to pre-service review. Check EIU policy CPCP028, which is one SUR713.035 Drug-Eluding Intracanalicular Punctal Plugs and Ocular Inserts _ _ Ins of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Sbsqt Plmt Drug Elut Oc 0445T to pre-service review. Check EIU policy CPCP028, which is one SUR713.035 Drug-Eluding Intracanalicular Punctal Plugs and Ocular Inserts _ _ Ins of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Insj Aqueous Drain Dev 0449T Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ 1St review. MP Criteria: Procedure/service reviewed against Medical Policy Insj Aqueous Drain Dev 0450T Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma 5/1/2021 12/31/2999 Each review. MP Criteria: Procedure/service reviewed against Medical Policy Remvl Aortic Ventr 0455T Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Cmpl Sys review. MP Criteria: Procedure/service reviewed against Medical Policy Prgrmg Eval Aortic 0462T Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Ventr Sys review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 32/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Visual Ep Test For 0464T to pre-service review. Check EIU policy CPCP028, which is one OTH903.033 Visual Evoked Potential Testing for Glaucoma _ _ Glaucoma of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Supchrdl Njx Rx W/O 0465T to pre-service review. Check EIU policy CPCP028, which is one OTH903.035 Suprachoroidal Injection of a Pharmacologic Agent _ _ Supply of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Insj Ch Wal Respir 0466T Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Eltrd/Ra review. MP Criteria: Procedure/service reviewed against Medical Policy Revj/Rplmnt Ch Respir 0467T Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Eltrd review. MP Criteria: Procedure/service reviewed against Medical Policy Rmvl Ch Wal Respir 0468T Criteria. Submit for predetermination to avoid post-service SUR706.009 Sleep Related Breathing Disorders: Surgical Management _ _ Eltrd/Ra review. EIU: Procedure/service not reimbursed by the Plan. Not subject 0472T Prgrmg Io Rta Eltrd Ra to pre-service review. Check EIU policy CPCP028, which is one SUR713.026 Retinal Prosthesis _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Reprgrmg Io Rta Eltrd 0473T to pre-service review. Check EIU policy CPCP028, which is one SUR713.026 Retinal Prosthesis _ _ Ra of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Insj Aqueous Drg Dev Io 0474T Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ Rsvr review. MP Criteria: Procedure/service reviewed against Medical Policy Fxjl Abl Lsr 1St 100 Sq 0479T Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Cm review. MP Criteria: Procedure/service reviewed against Medical Policy Fxjl Abl Lsr Ea Addl 0480T Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ 100Sqcm review. MP Criteria: Procedure/service reviewed against Medical Policy Tmvi Percutaneous 0483T Criteria. Submit for predetermination to avoid post-service SUR707.025 Transcatheter Mitral Valve Procedures _ _ Approach review. EIU: Procedure/service not reimbursed by the Plan. Not subject Oct Mid Ear I&R Use of Optical Coherence Tomography (OCT) in the Diagnosis and 0485T to pre-service review. Check EIU policy CPCP028, which is one MED201.046 _ _ Unilateral Treatment of Auditory System Conditions of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Oct Mid Ear I&R Use of Optical Coherence Tomography (OCT) in the Diagnosis and 0486T to pre-service review. Check EIU policy CPCP028, which is one MED201.046 _ _ Bilateral Treatment of Auditory System Conditions of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Near Ifr Spectrsc Of 0493T to pre-service review. Check EIU policy CPCP028, which is one SUR701.006 Foot Care Services _ _ Wounds of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cysto F/Urtl Optilume (Drug Coated Balloon) for the Treatment of Urethral 0499T to pre-service review. Check EIU policy CPCP028, which is one SUR710.026 _ _ Strix/Stenosis Stricture Conditions of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Near Ifr 2Img Mibmn 0507T to pre-service review. Check EIU policy CPCP028, which is one OTH903.025 Eyelid Thermal Pulsation _ _ Glnd I&R of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Pls Echo Us B1 Dns 0508T to pre-service review. Check EIU policy CPCP028, which is one RAD601.071 Pulse-Echo Ultrasound Bone Density Measurement _ _ Meas Tib of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Electroretinography (ERG), Multi-Focal Electroretinography 0509T Pattern Erg W/I&R to pre-service review. Check EIU policy CPCP028, which is one OTH903.036 5/15/2021 _ (mfERG) And Pattern Electroretinography (PERG) of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Rmvl Sinus Tarsi 0510T Criteria. Submit for predetermination to avoid post-service SUR705.027 Subtalar Arthroereisis (STA) _ _ Implant review. EIU: Procedure/service not reimbursed by the Plan. Not subject Rmvl&Rinsj Sinus Tarsi 0511T to pre-service review. Check EIU policy CPCP028, which is one SUR705.027 Subtalar Arthroereisis (STA) _ _ Implt of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Esw Integ Wnd Hlg 1St Extracorporeal Shock Wave Therapy for Musculoskeletal 0512T to pre-service review. Check EIU policy CPCP028, which is one SUR705.018 _ _ Wnd Indications and Soft Tissue Injuries of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Esw Integ Wnd Hlg Ea Extracorporeal Shock Wave Therapy for Musculoskeletal 0513T to pre-service review. Check EIU policy CPCP028, which is one SUR705.018 _ _ Addl Indications and Soft Tissue Injuries of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Biventricular Pacemakers (Cardiac Resynchronization Therapy) for 0516T Insj Wcs Lv Eltrd Only Criteria. Submit for predetermination to avoid post-service MED202.054 _ _ the Treatment of Heart Failure review. MP Criteria: Procedure/service reviewed against Medical Policy Biventricular Pacemakers (Cardiac Resynchronization Therapy) for 0517T Insj Wcs Lv Pg Compnt Criteria. Submit for predetermination to avoid post-service MED202.054 _ _ the Treatment of Heart Failure review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 33/83 MP Criteria: Procedure/service reviewed against Medical Policy Ev Cath Dir Chem Abltj 0524T Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ W/Img review. MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Interrog Dev Eval Iims 0529T Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and _ _ Ip review. Intracardiac Ischemia Detection Systems) EIU: Procedure/service not reimbursed by the Plan. Not subject Cont Rec Mvmt Do 6-10 Physiologic Recording of Movement Disorder Symptoms using 0533T to pre-service review. Check EIU policy CPCP028, which is one MED205.041 _ _ Days Motion Analysis Testing Devices of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cont Rec Mvmt Do Physiologic Recording of Movement Disorder Symptoms using 0534T to pre-service review. Check EIU policy CPCP028, which is one MED205.041 _ _ Setup&Train Motion Analysis Testing Devices of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cont Rec Mvmt Do Physiologic Recording of Movement Disorder Symptoms using 0535T to pre-service review. Check EIU policy CPCP028, which is one MED205.041 _ _ Reprt Cnfig Motion Analysis Testing Devices of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cont Rec Mvmt Do Dl Physiologic Recording of Movement Disorder Symptoms using 0536T to pre-service review. Check EIU policy CPCP028, which is one MED205.041 _ _ W/I&R Motion Analysis Testing Devices of our Clinical Payment and Coding Policy (CPCP). B1 Matrl Qual Tst Non Covered: Procedure/service not covered by the Plan. Not 0547T _ _ _ _ Mcrind Tib subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject 0548T Tprnl Balo Cntnc Dev Bi to pre-service review. Check EIU policy CPCP028, which is one SUR701.036 Implanted Adjustable Continence Therapy _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Tprnl Balo Cntnc Dev 0549T to pre-service review. Check EIU policy CPCP028, which is one SUR701.036 Implanted Adjustable Continence Therapy _ _ Uni of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Tprnl Balo Cntnc Dev 0550T to pre-service review. Check EIU policy CPCP028, which is one SUR701.036 Implanted Adjustable Continence Therapy _ _ Rmvl Ea of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Tprnl Balo Cntnc Dev 0551T to pre-service review. Check EIU policy CPCP028, which is one SUR701.036 Implanted Adjustable Continence Therapy _ _ Adjmt of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Evac Meibomian Glnd 0563T to pre-service review. Check EIU policy CPCP028, which is one OTH903.025 Eyelid Thermal Pulsation _ _ Heat Bi of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Orthopedic Applications of Stem Cell Therapy (Including Allograft Autol Cell Implt Adps 0565T Criteria. Submit for predetermination to avoid post-service SUR703.051 and Bone Substitute Products Used With Autologous Bone 4/15/2001 8/14/2021 Hrvg review. Marrow) EIU: Procedure/service not reimbursed by the Plan. Not subject Orthopedic Applications of Stem Cell Therapy (Including Allograft Autol Cell Implt Adps 0565T to pre-service review. Check EIU policy CPCP028, which is one SUR703.051 and Bone Substitute Products Used With Autologous Bone 8/15/2021 _ Hrvg of our Clinical Payment and Coding Policy (CPCP). Marrow) MP Criteria: Procedure/service reviewed against Medical Policy Orthopedic Applications of Stem Cell Therapy (Including Allograft Autol Cell Implt Adps 0566T Criteria. Submit for predetermination to avoid post-service SUR703.051 and Bone Substitute Products Used With Autologous Bone 4/15/2001 8/14/2021 Njx review. Marrow) EIU: Procedure/service not reimbursed by the Plan. Not subject Orthopedic Applications of Stem Cell Therapy (Including Allograft Autol Cell Implt Adps 0566T to pre-service review. Check EIU policy CPCP028, which is one SUR703.051 and Bone Substitute Products Used With Autologous Bone 8/15/2021 _ Njx of our Clinical Payment and Coding Policy (CPCP). Marrow) MP Criteria: Procedure/service reviewed against Medical Policy Perq Impltj/Rplcmt 0587T Criteria. Submit for predetermination to avoid post-service MED205.035 Percutaneous Tibial Nerve Stimulation (PTNS) 3/1/2021 _ Isdns Ptn review. MP Criteria: Procedure/service reviewed against Medical Policy Revision/Removal Isdns 0588T Criteria. Submit for predetermination to avoid post-service MED205.035 Percutaneous Tibial Nerve Stimulation (PTNS) 3/1/2021 _ Ptn review. MP Criteria: Procedure/service reviewed against Medical Policy Elec Alys Smpl Prgrmg 0589T Criteria. Submit for predetermination to avoid post-service MED205.035 Percutaneous Tibial Nerve Stimulation (PTNS) 3/1/2021 _ Iins review. MP Criteria: Procedure/service reviewed against Medical Policy Elec Alys Cplx Prgrmg 0590T Criteria. Submit for predetermination to avoid post-service MED205.035 Percutaneous Tibial Nerve Stimulation (PTNS) 3/1/2021 _ Iins review. EIU: Procedure/service not reimbursed by the Plan. Not subject Transdermal Gfr 0602T to pre-service review. Check EIU policy CPCP028, which is one MED201.050 Transdermal Glomerular Filtration Rate 4/1/2021 _ Measurements of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Transdermal Gfr 0603T to pre-service review. Check EIU policy CPCP028, which is one MED201.050 Transdermal Glomerular Filtration Rate 4/1/2021 _ Monitoring of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Eye Mvmt Alys W/O Experimental, Investigational and/or Unproven 0615T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 5/15/2021 _ Calbrj I&R Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Evasc Ven Artlz Tibl/Prnl Experimental, Investigational and/or Unproven 0620T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Vn Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 34/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Trabeculostomy Interno Experimental, Investigational and/or Unproven 0621T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Laser Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Trabeculostomy Int Lsr Experimental, Investigational and/or Unproven 0622T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ W/Scp Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Auto Quantification C Experimental, Investigational and/or Unproven 0623T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Plaque Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Auto Quan C Plaq Data Experimental, Investigational and/or Unproven 0624T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Prep Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Auto Quan C Plaq Cptr Experimental, Investigational and/or Unproven 0625T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Alys Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Experimental, Investigational and/or Unproven 0626T Auto Quan C Plaq I&R to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Perq Njx Algc Fluor Experimental, Investigational and/or Unproven 0627T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Lmbr 1St Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Perq Njx Algc Fluor Experimental, Investigational and/or Unproven 0628T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Lmbr Ea Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Perq Njx Algc Ct Lmbr Experimental, Investigational and/or Unproven 0629T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ 1St Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Perq Njx Algc Ct Lmbr Experimental, Investigational and/or Unproven 0630T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Ea Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Tc Vis Lit Hyperspectral Experimental, Investigational and/or Unproven 0631T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Img Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Perq Tcat Us Abltj Nrv P- Experimental, Investigational and/or Unproven 0632T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Art Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Wrls Skn Snr Anisotropy Experimental, Investigational and/or Unproven 0639T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 _ _ Meas Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Ncntc Nr Ifr Spctrsc Experimental, Investigational and/or Unproven 0640T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 7/1/2021 _ Wnd Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Ncntc Nr Ifr Spctrsc Experimental, Investigational and/or Unproven 0641T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 7/1/2021 _ Wnd Img Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Ncntc Nr Ifr Spctrsc Experimental, Investigational and/or Unproven 0642T to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 7/1/2021 _ Wnd I&R Procedures/Services of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Tcat L Ventr Rstrj Dev Experimental, Investigational and/or Unproven 0643T Criteria. Submit for predetermination to avoid post-service ADM1001.032 7/1/2021 _ Implt Procedures/Services review. MP Criteria: Procedure/service reviewed against Medical Policy Tcat Impltj C Sins Rdctj Experimental, Investigational and/or Unproven 0645T Criteria. Submit for predetermination to avoid post-service ADM1001.032 7/1/2021 _ Dev Procedures/Services review. MP Criteria: Procedure/service reviewed against Medical Policy Ttvi/Rplcmt W/Prstc Vlv Experimental, Investigational and/or Unproven 0646T Criteria. Submit for predetermination to avoid post-service ADM1001.032 7/1/2021 _ Perq Procedures/Services review. MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Prgrmg Dev Eval Scrms 0650T Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and 7/1/2021 _ Remote review. Intracardiac Ischemia Detection Systems) EIU: Procedure/service not reimbursed by the Plan. Not subject Vrt Bdy Tethering Ant Vertebral Body Stapling and Vertebral Body Tethering for the 0656T to pre-service review. Check EIU policy CPCP028, which is one SUR705.046 7/1/2021 _ <7 Seg Treatment of Scoliosis of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Vrt Bdy Tethering Ant Vertebral Body Stapling and Vertebral Body Tethering for the 0657T to pre-service review. Check EIU policy CPCP028, which is one SUR705.046 7/1/2021 _ 8+ Seg Treatment of Scoliosis of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Don Hysterectomy 0664T Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss 7/1/2021 8/14/2021 Open Cdvr review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 35/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Don Hysterectomy 0664T to pre-service review. Check EIU policy CPCP028, which is one OB402.023 Services for Infertility and Recurrent Fetal Loss 8/15/2021 12/31/2999 Open Cdvr of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Don Hysterectomy 0665T Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss 7/1/2021 8/14/2021 Open Liv review. EIU: Procedure/service not reimbursed by the Plan. Not subject Don Hysterectomy 0665T to pre-service review. Check EIU policy CPCP028, which is one OB402.023 Services for Infertility and Recurrent Fetal Loss 8/15/2021 12/31/2999 Open Liv of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Don Hysterectomy Laps 0666T Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss 7/1/2021 8/14/2021 Liv review. EIU: Procedure/service not reimbursed by the Plan. Not subject Don Hysterectomy Laps 0666T to pre-service review. Check EIU policy CPCP028, which is one OB402.023 Services for Infertility and Recurrent Fetal Loss 8/15/2021 12/31/2999 Liv of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Don Hysterectomy Rcp 0667T Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss 7/1/2021 8/14/2021 Uter review. EIU: Procedure/service not reimbursed by the Plan. Not subject Don Hysterectomy Rcp 0667T to pre-service review. Check EIU policy CPCP028, which is one OB402.023 Services for Infertility and Recurrent Fetal Loss 8/15/2021 12/31/2999 Uter of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Bkbench Prep Don Uter 0668T Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss 7/1/2021 8/14/2021 Algrft review. EIU: Procedure/service not reimbursed by the Plan. Not subject Bkbench Prep Don Uter 0668T to pre-service review. Check EIU policy CPCP028, which is one OB402.023 Services for Infertility and Recurrent Fetal Loss 8/15/2021 12/31/2999 Algrft of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Bkbench Rcnstj Don 0669T Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss 7/1/2021 8/14/2021 Uter Ven review. EIU: Procedure/service not reimbursed by the Plan. Not subject Bkbench Rcnstj Don 0669T to pre-service review. Check EIU policy CPCP028, which is one OB402.023 Services for Infertility and Recurrent Fetal Loss 8/15/2021 12/31/2999 Uter Ven of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Bkbench Rcnstj Don 0670T Criteria. Submit for predetermination to avoid post-service OB402.023 Services for Infertility and Recurrent Fetal Loss 7/1/2021 8/14/2021 Uter Artl review. EIU: Procedure/service not reimbursed by the Plan. Not subject Bkbench Rcnstj Don 0670T to pre-service review. Check EIU policy CPCP028, which is one OB402.023 Services for Infertility and Recurrent Fetal Loss 8/15/2021 12/31/2999 Uter Artl of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Outside State A0021 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ Ambulance Serv review. Noninterest Escort In Non Covered: Procedure/service not covered by the Plan. Not A0080 _ _ _ _ Non Er subject to pre-service review. Interest Escort In Non Non Covered: Procedure/service not covered by the Plan. Not A0090 _ _ _ _ Er subject to pre-service review. Nonemergency Non Covered: Procedure/service not covered by the Plan. Not A0100 _ _ _ _ Transport Taxi subject to pre-service review. Nonemergency Non Covered: Procedure/service not covered by the Plan. Not A0110 _ _ _ _ Transport Bus subject to pre-service review. Noner Transport Mini- Non Covered: Procedure/service not covered by the Plan. Not A0120 _ _ _ _ Bus subject to pre-service review. Noner Transport Non Covered: Procedure/service not covered by the Plan. Not A0130 _ _ _ _ Wheelch Van subject to pre-service review. Nonemergency Non Covered: Procedure/service not covered by the Plan. Not A0140 _ _ _ _ Transport Air subject to pre-service review. Noner Transport Case Non Covered: Procedure/service not covered by the Plan. Not A0160 _ _ _ _ Worker subject to pre-service review. Transport Parking Non Covered: Procedure/service not covered by the Plan. Not A0170 _ _ _ _ Fees/Tolls subject to pre-service review. Noner Transport Non Covered: Procedure/service not covered by the Plan. Not A0180 _ _ _ _ Lodgng Recip subject to pre-service review. Noner Transport Meals Non Covered: Procedure/service not covered by the Plan. Not A0190 _ _ _ _ Recip subject to pre-service review. Noner Transport Non Covered: Procedure/service not covered by the Plan. Not A0200 _ _ _ _ Lodgng Escrt subject to pre-service review. Noner Transport Meals Non Covered: Procedure/service not covered by the Plan. Not A0210 _ _ _ _ Escort subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy A0426 Als 0 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy A0428 Bls Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ review. MP Criteria: Procedure/service reviewed against Medical Fixed Wing Air A0430 Policy Criteria, may require Prior Authorization per contract ADM1001.005 Ambulance and Medical Transport Services _ _ Transport agreement. MP Criteria: Procedure/service reviewed against Medical Policy Rotary Wing Air A0431 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ Transport review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 36/83 MP Criteria: Procedure/service reviewed against Medical A0435 Fixed Wing Air Mileage Policy Criteria, may require Prior Authorization per contract ADM1001.005 Ambulance and Medical Transport Services _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy Rotary Wing Air A0436 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ Mileage review. Noncovered Ambulance Non Covered: Procedure/service not covered by the Plan. Not A0888 _ _ _ _ Mileage subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Ambulance A0998 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ Response/Treatment review. Unlisted Ambulance Unlisted: Procedure/service not specifically defined or A0999 _ _ _ _ Service classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not A4267 Male Condom _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Sacral Nerve Stim Test A4290 Policy Criteria, may require Prior Authorization per contract SUR710.018 Sacral Nerve Neuromodulation/Stimulation _ _ Lead agreement. Unlisted: Procedure/service not specifically defined or A4335 Incontinence Supply _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or A4421 Ostomy Supply Misc _ _ _ _ classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not A4458 Reusable Enema Bag _ _ _ _ subject to pre-service review. Incontinence Garment Non Covered: Procedure/service not covered by the Plan. Not A4520 _ _ _ _ Anytype subject to pre-service review. Nondisp Underpads All Non Covered: Procedure/service not covered by the Plan. Not A4553 _ _ _ _ Sizes subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not A4554 Disposable Underpads _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Ca Tx E-Stim A4555 Criteria. Submit for predetermination to avoid post-service MED201.039 Tumor Treating Fields (TTF) Therapy _ _ Electr/Transduc review. EIU: Procedure/service not reimbursed by the Plan. Not subject Topical Hyperbaric to pre-service review. Check EIU policy CPCP028, which is one PSY301.014 Autism Spectrum Disorders (ASD) A4575 Oxygen Chamber _ _ of our Clinical Payment and Coding Policy (CPCP). May require THE801.003 Hyperbaric Oxygen (HBO2) Therapy Disposable Prior Authorization per contract agreement Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Sleeve Inter Limb Comp MED202.060 Venous Ulcers A4600 Criteria. Submit for predetermination to avoid post-service _ _ Dev MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis EIU: Procedure/service not reimbursed by the Plan. Not subject Infrared Ht Sys A4639 to pre-service review. Check EIU policy CPCP028, which is one DME101.045 Skin Contact Monochromatic Infrared Energy (MIRE) _ _ Replcmnt Pad of our Clinical Payment and Coding Policy (CPCP). Radiopharm Dx Agent Unlisted: Procedure/service not specifically defined or A4641 _ _ _ _ Noc classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or A4649 Surgical Supplies _ _ _ _ classified, maybe subject to contract/clinical review. Repair/Maint Cont Non Covered: Procedure/service not covered by the Plan. Not A4890 _ _ _ _ Hemo Equip subject to pre-service review. Misc Dialysis Supplies Unlisted: Procedure/service not specifically defined or A4913 _ _ _ _ Noc classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not A4927 Non-Sterile Gloves _ _ _ _ subject to pre-service review. Reusable Oral Non Covered: Procedure/service not covered by the Plan. Not A4931 _ _ _ _ Thermometer subject to pre-service review. Reusable Rectal Non Covered: Procedure/service not covered by the Plan. Not A4932 _ _ _ _ Thermometer subject to pre-service review. Modification Diabetic Unlisted: Procedure/service not specifically defined or A5507 _ _ _ _ Shoe classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Wound Warming A6000 to pre-service review. Check EIU policy CPCP028, which is one DME101.050 Noncontact Normothermic Wound Therapy _ _ Wound Cover of our Clinical Payment and Coding Policy (CPCP). Wound Filler Gel/Paste Unlisted: Procedure/service not specifically defined or A6261 _ _ _ _ /Oz classified, maybe subject to contract/clinical review. Wound Filler Dry Form / Unlisted: Procedure/service not specifically defined or A6262 _ _ _ _ Gram classified, maybe subject to contract/clinical review. Compres Burn Garment Unlisted: Procedure/service not specifically defined or A6512 _ _ _ _ Noc classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or A6549 G Compression Stocking _ _ _ _ classified, maybe subject to contract/clinical review. Misc/Exper Non- Non Covered: Procedure/service not covered by the Plan. Not A9150 _ _ _ _ Prescript Dru subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not A9152 Single Vitamin Nos _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not A9153 Multi-Vitamin Nos _ _ _ _ subject to pre-service review. Non-Covered Item Or Non Covered: Procedure/service not covered by the Plan. Not A9270 _ _ _ _ Service subject to pre-service review. Monitoring Unlisted: Procedure/service not specifically defined or A9279 _ _ _ _ Feature/Devicenoc classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or A9280 Alert Device Noc _ _ _ _ classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 37/83 Non Covered: Procedure/service not covered by the Plan. Not A9282 Wig Any Type _ _ _ _ subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Inversion Eversion Cor A9285 to pre-service review. Check EIU policy CPCP028, which is one DME103.001 Orthotics _ _ Devic of our Clinical Payment and Coding Policy (CPCP). Non Covered: Procedure/service not covered by the Plan. Not A9300 Exercise Equipment _ _ _ _ subject to pre-service review. Gad-Base Mr Contrast Unlisted: Procedure/service not specifically defined or A9579 _ _ _ _ Nos 1Ml classified, maybe subject to contract/clinical review. Pet Dx For Tumor Id Unlisted: Procedure/service not specifically defined or A9597 _ _ _ _ Noc classified, maybe subject to contract/clinical review. Pet Dx For Non-Tumor Unlisted: Procedure/service not specifically defined or A9598 _ _ _ _ Id Noc classified, maybe subject to contract/clinical review. Non-Rad Contrast Unlisted: Procedure/service not specifically defined or A9698 _ _ _ _ Materialnoc classified, maybe subject to contract/clinical review. Radiopharm Rx Agent Unlisted: Procedure/service not specifically defined or A9699 _ _ _ _ Noc classified, maybe subject to contract/clinical review. Supply/Accessory/Servi Unlisted: Procedure/service not specifically defined or A9900 _ _ _ _ ce classified, maybe subject to contract/clinical review. Dme Supply Or Unlisted: Procedure/service not specifically defined or A9999 _ _ _ _ Accessory Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Enzyme Cartridge B4105 Criteria. Submit for predetermination to avoid post-service MED201.011 Nutritional Support _ _ Enteral Nut review. Enteral Supp Not Unlisted: Procedure/service not specifically defined or B9998 _ _ _ _ Otherwise C classified, maybe subject to contract/clinical review. Parenteral Supp Not Unlisted: Procedure/service not specifically defined or B9999 _ _ _ _ Othrws C classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Hemostatic Agent Gi C1052 to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 Experimental, Investigational and/or Unproven Procedures/Services 5/15/2021 _ Topic of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Cath trans intra C1761 Criteria. Submit for predetermination to avoid post-service N/A N/A 7/1/2021 _ litho/coro review. MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac C1764 Event Recorder Cardiac Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and _ _ review. Intracardiac Ischemia Detection Systems) MP Criteria: Procedure/service reviewed against Medical Policy Joint Device Unicondylar Interpositional Spacer as a Treatment of C1776 Criteria. Submit for predetermination to avoid post-service SUR705.024 _ _ (Implantable) Unicompartmental Arthritis of the Knee review. MP Criteria: Procedure/service reviewed against Medical Policy Ocular Imp Aqueous C1783 Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ Drain De review. MP Criteria: Procedure/service reviewed against Medical Policy C1817 Septal Defect Imp Sys Criteria. Submit for predetermination to avoid post-service SUR707.024 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Integrated C1818 Criteria. Submit for predetermination to avoid post-service OTH903.030 Keratoprosthesis _ _ Keratoprosthesis review. MP Criteria: Procedure/service reviewed against Medical Policy Gen Neuro Carot Sinus C1825 Criteria. Submit for predetermination to avoid post-service THE801.034 Baroreflex Stimulation Devices 2/1/2021 _ Baro review. EIU: Procedure/service not reimbursed by the Plan. Not subject Retinal Prosth Int/Ext C1841 to pre-service review. Check EIU policy CPCP028, which is one SUR713.026 Retinal Prosthesis _ _ Comp of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject C1842 Retinal Prosth Add-On to pre-service review. Check EIU policy CPCP028, which is one SUR713.026 Retinal Prosthesis _ _ of our Clinical Payment and Coding Policy (CPCP). Implant/Insert Device Unlisted: Procedure/service not specifically defined or C1889 _ _ _ _ Noc classified, maybe subject to contract/clinical review. Endovascular Therapies for Extracranial Vertebral Artery Disease MP Criteria: Procedure/service reviewed against Medical Policy SUR701.041 Cath Translumin Drug- Extracranial Carotid Angioplasty or Stenting C2623 Criteria. Submit for predetermination to avoid post-service SUR701.028 _ _ Coat Intracranial Stenting or Angioplasty, including Endovascular review. SUR701.027 Procedures MP Criteria: Procedure/service reviewed against Medical Policy Wireless Pressure Cardiac Hemodynamic Monitoring for the Management of Heart C2624 Criteria. Submit for predetermination to avoid post-service MED202.058 _ _ Sensor Failure in the Outpatient Setting review. Unlisted: Procedure/service not specifically defined or C2698 Brachytx Stranded Nos _ _ _ _ classified, maybe subject to contract/clinical review. Brachytx Non-Stranded Unlisted: Procedure/service not specifically defined or C2699 _ _ _ _ Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Daratumumab C9062 Policy Criteria, may require Prior Authorization per contract RX502.061 N/A _ 12/31/2020 Hyaluronidase agreement. MP Criteria: Procedure/service reviewed against Medical Mitomycin C9064 Policy Criteria, may require Prior Authorization per contract RX502.061 N/A _ 12/31/2020 Pyelocalyceal Inst agreement. MP Criteria: Procedure/service reviewed against Medical Sacituzumab Govitecan- C9066 Policy Criteria, may require Prior Authorization per contract RX502.061 N/A _ 12/31/2020 Hziy agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 38/83 MP Criteria: Procedure/service reviewed against Medical Policy C9072 Inj Imm Glob Asceniv Criteria. Submit for predetermination to avoid post-service RX504.003 Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and 2/1/2021 3/1/2021 review. Subcutaneous Ig [SCIG]) MP Criteria: Procedure/service reviewed against Medical Policy Brexucabtagene C9073 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 2/1/2021 3/1/2021 Autoleucel Ca review. MP Criteria: Procedure/service reviewed against Medical Policy C9074 Injection lumasiran Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 5/1/2021 _ review. MP Criteria: Procedure/service reviewed against Medical Policy Injection casimersen C9075 Criteria. Submit for predetermination to avoid post-service N/A N/A 7/1/2021 _ 10 mg review. MP Criteria: Procedure/service reviewed against Medical Policy C9076 Lisocabtagene car pos t Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 7/1/2021 _ review. Intravitreal Angiogenesis Inhibitors for Retinal Vascular Disorders MP Criteria: Procedure/service reviewed against Medical OTH903.027 Intravitreal Angiogenesis Inhibitors for Choroidal Vascular C9257 Bevacizumab Injection Policy Criteria, may require Prior Authorization per contract OTH903.020 Conditions _ _ agreement. OTH903.015 Photodynamic Therapy (PDT) for Choroidal Neovascularization (CNV)

EIU: Procedure/service not reimbursed by the Plan. Not subject Veritas Collagen Matrix C9354 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ _ Cm1 of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Tenoglide Tendon Prot C9356 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ _ Cm1 of our Clinical Payment and Coding Policy (CPCP).

Dermal Substitute Native Non-Denatured EIU: Procedure/service not reimbursed by the Plan. Not subject Collagen Fetal Bovine C9358 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ _ Origin (Surgimend of our Clinical Payment and Coding Policy (CPCP). Collagen Matrix) Per 0.5 Square Centimeters MP Criteria: Procedure/service reviewed against Medical Orthopedic Applications of Stem Cell Therapy (Including Allograft Implnt bon void filler- C9359 Policy Criteria, may require Prior Authorization per contract SUR703.051 and Bone Substitute Products Used With Autologous Bone 4/1/2021 _ putty agreement. Marrow) EIU: Procedure/service not reimbursed by the Plan. Not subject C9360 Surgimend Neonatal to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ _ of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Orthopedic Applications of Stem Cell Therapy (Including Allograft Implnt bon void filler- C9362 Policy Criteria, may require Prior Authorization per contract SUR703.051 and Bone Substitute Products Used With Autologous Bone 4/1/2021 _ strip agreement. Marrow) EIU: Procedure/service not reimbursed by the Plan. Not subject Integra Meshed Bil C9363 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Wound Mat of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Porcine Implant C9364 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ _ Permacol of our Clinical Payment and Coding Policy (CPCP). Unclassified Drugs Or Unlisted: Procedure/service not specifically defined or C9399 _ _ _ _ Biologicals classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy U/S Trtmt Not C9734 Criteria. Submit for predetermination to avoid post-service SUR701.022 Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) _ _ Leiomyomata review. MP Criteria: Procedure/service reviewed against Medical Policy Cystoscopy Prostatic Prostatic Urethral Lift (PUL) for the Treatment of Benign Prostatic C9739 Criteria. Submit for predetermination to avoid post-service SUR710.023 _ _ Imp 1-2 Hyperplasia (BPH) review. MP Criteria: Procedure/service reviewed against Medical Policy Prostatic Urethral Lift (PUL) for the Treatment of Benign Prostatic C9740 Cysto Impl 4 Or More Criteria. Submit for predetermination to avoid post-service SUR710.023 _ _ Hyperplasia (BPH) review. EIU: Procedure/service not reimbursed by the Plan. Not subject Nasal Endo Eustachian C9745 to pre-service review. Check EIU policy CPCP028, which is one N/A N/A _ 12/31/2020 Tube of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical C9747 Ablation Hifu Prostate Policy Criteria, may require Prior Authorization per contract SUR717.014 High-Intensity Focused Ultrasound (HIFU) for Treatment of Cancer _ 12/31/2020 agreement. EIU: Procedure/service not reimbursed by the Plan. Not subject Repair Nasal Stenosis C9749 to pre-service review. Check EIU policy CPCP028, which is one N/A N/A _ 12/31/2020 W/Imp of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Intraosseous des C9752 Criteria. Submit for predetermination to avoid post-service N/A N/A 7/1/2021 _ lumb/sacrum review. MP Criteria: Procedure/service reviewed against Medical Policy Intraosseous destruct C9753 Criteria. Submit for predetermination to avoid post-service N/A N/A 7/1/2021 _ add'l review. MP Criteria: Procedure/service reviewed against Medical Policy Revasc Intravasc Experimental, Investigational and/or Unproven C9764 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 _ Lithotripsy Procedures/Services review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 39/83 MP Criteria: Procedure/service reviewed against Medical Policy Revasc Intra Lithotrip- Experimental, Investigational and/or Unproven C9765 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 _ Stent Procedures/Services review. MP Criteria: Procedure/service reviewed against Medical Policy Revasc Intra Lithotrip- Experimental, Investigational and/or Unproven C9766 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 _ Ather Procedures/Services review. MP Criteria: Procedure/service reviewed against Medical Policy Revasc Lithotrip-Stent- Experimental, Investigational and/or Unproven C9767 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 _ Ather Procedures/Services review. EIU: Procedure/service not reimbursed by the Plan. Not subject Endo Us-Guide Hep Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic C9768 to pre-service review. Check EIU policy CPCP028, which is one SUR701.043 3/1/2021 _ Porto Grad Pressure Gradient Measurement of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Endo Us-Guide Hep Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic C9768 Criteria. Submit for predetermination to avoid post-service SUR701.043 _ 2/28/2021 Porto Grad Pressure Gradient Measurement review. MP Criteria: Procedure/service reviewed against Medical Policy Vitrec/mech pars, C9770 Criteria. Submit for predetermination to avoid post-service RX501.098 Gene Therapy for Inherited Retinal Dystrophy 4/1/2021 _ subret inj review. EIU: Procedure/service not reimbursed by the Plan. Not subject Nsl/Sins Cryo Post Nasal C9771 to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 Experimental, Investigational and/or Unproven Procedures/Services 5/15/2021 _ Tis of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Revasc Lithotrip Experimental, Investigational and/or Unproven C9772 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 8/14/2021 Tibi/Perone Procedures/Services review. EIU: Procedure/service not reimbursed by the Plan. Not subject Revasc Lithotrip Experimental, Investigational and/or Unproven C9772 to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 8/15/2021 _ Tibi/Perone Procedures/Services of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Revasc Lithotr-Stent Experimental, Investigational and/or Unproven C9773 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 8/14/2021 Tib/Per Procedures/Services review. EIU: Procedure/service not reimbursed by the Plan. Not subject Revasc Lithotr-Stent Experimental, Investigational and/or Unproven C9773 to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 8/15/2021 _ Tib/Per Procedures/Services of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Revasc Lithotr-Ather Experimental, Investigational and/or Unproven C9774 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 8/14/2021 Tib/Per Procedures/Services review. EIU: Procedure/service not reimbursed by the Plan. Not subject Revasc Lithotr-Ather Experimental, Investigational and/or Unproven C9774 to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 8/15/2021 _ Tib/Per Procedures/Services of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Revasc Lith-Sten-Ath Experimental, Investigational and/or Unproven C9775 Criteria. Submit for predetermination to avoid post-service ADM1001.032 5/15/2021 8/14/2021 Tib/Per Procedures/Services review. EIU: Procedure/service not reimbursed by the Plan. Not subject Revasc Lith-Sten-Ath Experimental, Investigational and/or Unproven C9775 to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 8/15/2021 _ Tib/Per Procedures/Services of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Esophag Mucosal Integ C9777 to pre-service review. Check EIU policy CPCP028, which is one ADM1001.032 EIU Procedures/Services 8/15/2021 12/31/2999 Add-On of our Clinical Payment and Coding Policy (CPCP). Inpnt Stay Radiolabeled Unlisted: Procedure/service not specifically defined or C9898 _ _ _ _ Item classified, maybe subject to contract/clinical review. Inpt Implant Pros Dev Unlisted: Procedure/service not specifically defined or C9899 _ _ _ _ No Cov classified, maybe subject to contract/clinical review. Unspecified Diagnostic Unlisted: Procedure/service not specifically defined or D0999 _ _ _ _ Procedure By Report classified, maybe subject to contract/clinical review.

AstraZeneca Covid-19 Non Covered: Procedure/service not covered by the Plan. Not D1705 vaccine administration _ _ 8/15/2021 _ subject to pre-service review. – first dose

AstraZeneca Covid-19 Non Covered: Procedure/service not covered by the Plan. Not D1706 vaccine administration _ _ 3/15/2021 _ subject to pre-service review. – second dose

Unspecified Preventive Unlisted: Procedure/service not specifically defined or D1999 _ _ _ _ Procedure By Report classified, maybe subject to contract/clinical review.

Unspecified Restorative Unlisted: Procedure/service not specifically defined or D2999 _ _ _ _ Procedure By Report classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not D3410 Apicoectomy - Anterior _ _ _ _ subject to pre-service review. Unspecified Endodontic Unlisted: Procedure/service not specifically defined or D3999 _ _ _ _ Procedure By Report classified, maybe subject to contract/clinical review.

Unspecified Periodontal Unlisted: Procedure/service not specifically defined or D4999 _ _ _ _ Procedure By Report classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 40/83 Unspecified Removable Unlisted: Procedure/service not specifically defined or D5899 Prosthodontic _ _ _ _ classified, maybe subject to contract/clinical review. Procedure By Report Unspecified Unlisted: Procedure/service not specifically defined or D5999 Maxillofacial Prosthesis _ _ _ _ classified, maybe subject to contract/clinical review. By Report Unspecified Implant Unlisted: Procedure/service not specifically defined or D6199 _ _ _ _ Procedure By Report classified, maybe subject to contract/clinical review. Unspecified Fixed Unlisted: Procedure/service not specifically defined or D6999 Prosthodontic _ _ _ _ classified, maybe subject to contract/clinical review. Procedure By Report Extraction Erupted Tooth Requiring Removal Of Bone And/Or Sectioning Of Non Covered: Procedure/service not covered by the Plan. Not D7210 _ _ _ _ Tooth And Including subject to pre-service review. Elevation Of Mucoperiosteal Flap If Indicated Removal Of Impacted Non Covered: Procedure/service not covered by the Plan. Not D7220 _ _ _ _ Tooth - Soft Tissue subject to pre-service review.

Removal Of Impacted Non Covered: Procedure/service not covered by the Plan. Not D7230 _ _ _ _ Tooth - Partially Bony subject to pre-service review. Unspecified Oral Unlisted: Procedure/service not specifically defined or D7999 Surgery Procedure By _ _ _ _ classified, maybe subject to contract/clinical review. Report Removable Appliance Non Covered: Procedure/service not covered by the Plan. Not D8210 _ _ _ _ Therapy subject to pre-service review. Fixed Appliance Non Covered: Procedure/service not covered by the Plan. Not D8220 _ _ _ _ Therapy subject to pre-service review. Unspecified Unlisted: Procedure/service not specifically defined or D8999 Orthodontic Procedure _ _ _ _ classified, maybe subject to contract/clinical review. By Report Teledentistry - Non Covered: Procedure/service not covered by the Plan. Not D9995 Synchronous; Real-Time _ _ _ _ subject to pre-service review. Encounter Teledentistry - Asynchronous; Non Covered: Procedure/service not covered by the Plan. Not D9996 Information Stored And _ _ _ _ subject to pre-service review. Forwarded To Dentist For Subsequent Review

Unspecified Adjunctive Unlisted: Procedure/service not specifically defined or D9999 _ _ _ _ Procedure By Report classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Water Pressure E0187 Criteria. Submit for predetermination to avoid post-service DME101.001 Hospital Beds and Related Equipment _ _ Mattress review. Electric Heat Pad Non Covered: Procedure/service not covered by the Plan. Not E0210 _ _ _ _ Standard subject to pre-service review. Water Circ Heat Pad W Non Covered: Procedure/service not covered by the Plan. Not E0217 _ _ _ _ Pump subject to pre-service review. Fluid Circ Cold Pad W Non Covered: Procedure/service not covered by the Plan. Not E0218 _ _ _ _ Pump subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Infrared Heating Pad E0221 to pre-service review. Check EIU policy CPCP028, which is one DME101.045 Skin Contact Monochromatic Infrared Energy (MIRE) _ _ System of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Wound Warming E0231 to pre-service review. Check EIU policy CPCP028, which is one DME101.050 Noncontact Normothermic Wound Therapy _ _ Device of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject E0232 Warming Card For Nwt to pre-service review. Check EIU policy CPCP028, which is one DME101.050 Noncontact Normothermic Wound Therapy _ _ of our Clinical Payment and Coding Policy (CPCP). Pump For Water Non Covered: Procedure/service not covered by the Plan. Not E0236 _ _ _ _ Circulating P subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0240 Bath/Shower Chair _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0241 Bath Tub Wall Rail _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0242 Bath Tub Rail Floor _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0243 Toilet Rail _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0244 Toilet Seat Raised _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0245 Tub Stool Or Bench _ _ _ _ subject to pre-service review. Transfer Tub Rail Non Covered: Procedure/service not covered by the Plan. Not E0246 _ _ _ _ Attachment subject to pre-service review. Trans Bench W/Wo Non Covered: Procedure/service not covered by the Plan. Not E0247 _ _ _ _ Comm Open subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 41/83 Hdtrans Bench W/Wo Non Covered: Procedure/service not covered by the Plan. Not E0248 _ _ _ _ Comm Open subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0273 Bed Board _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0274 Over-Bed Table _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy E0280 Bed Cradle Criteria. Submit for predetermination to avoid post-service DME101.001 Hospital Beds and Related Equipment _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Hosp Bed Fx Ht W/O E0290 Criteria. Submit for predetermination to avoid post-service DME101.001 Hospital Beds and Related Equipment _ _ Rails W/M review. MP Criteria: Procedure/service reviewed against Medical Policy Hosp Bed Var Ht No Sr E0292 Criteria. Submit for predetermination to avoid post-service DME101.001 Hospital Beds and Related Equipment _ _ W/Matt review. MP Criteria: Procedure/service reviewed against Medical Policy Hosp Bed Var Ht No Sr E0293 Criteria. Submit for predetermination to avoid post-service DME101.001 Hospital Beds and Related Equipment _ _ No Mat review. Bed Accessory Non Covered: Procedure/service not covered by the Plan. Not E0315 _ _ _ _ Brd/Tbl/Supprt subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E0316 Bed Safety Enclosure _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Powered Air Mattress E0372 Criteria. Submit for predetermination to avoid post-service DME101.001 Hospital Beds and Related Equipment _ _ Overlay review. Topical Ox Deliver Sys Unlisted: Procedure/service not specifically defined or E0446 _ _ _ _ Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Oral Device/Appliance Diagnosis and Medical Management of Obstructive Sleep Apnea E0485 Policy Criteria, may require Prior Authorization per contract MED204.005 _ _ Prefab Syndrome agreement. EIU: Procedure/service not reimbursed by the Plan. Not subject E0487 Electronic Spirometer to pre-service review. Check EIU policy CPCP028, which is one DME101.040 Home Spirometry _ _ of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac E0616 Cardiac Event Recorder Criteria. Submit for predetermination to avoid post-service MED202.003 Telemetry, Implantable Cardiac Rhythm Event Monitors, and _ _ review. Intracardiac Ischemia Detection Systems) MP Criteria: Procedure/service reviewed against Medical Policy Automatic Ext E0617 Criteria. Submit for predetermination to avoid post-service DME101.021 Nonwearable Automatic External Defibrillator (AED) for Home Use _ _ Defibrillator review. Patient Lift Bathroom Unlisted: Procedure/service not specifically defined or E0625 _ _ _ _ Or Toi classified, maybe subject to contract/clinical review. Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pneuma Compresor MED202.060 Venous Ulcers E0650 Criteria. Submit for predetermination to avoid post-service _ _ Non-Segment MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pneum Compressor MED202.060 Venous Ulcers E0651 Criteria. Submit for predetermination to avoid post-service _ _ Segmental MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pneum Compres W/Cal MED202.060 Venous Ulcers E0652 Criteria. Submit for predetermination to avoid post-service _ _ Pressure MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Appliance MED202.060 Venous Ulcers E0655 Criteria. Submit for predetermination to avoid post-service _ _ Half Arm MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Segmental Pneumatic MED202.060 Venous Ulcers E0656 Criteria. Submit for predetermination to avoid post-service _ _ Trunk MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Segmental Pneumatic MED202.060 Venous Ulcers E0657 Criteria. Submit for predetermination to avoid post-service _ _ Chest MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Appliance MED202.060 Venous Ulcers E0660 Criteria. Submit for predetermination to avoid post-service _ _ Full Leg MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Appliance MED202.060 Venous Ulcers E0665 Criteria. Submit for predetermination to avoid post-service _ _ Full Arm MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Appliance MED202.060 Venous Ulcers E0666 Criteria. Submit for predetermination to avoid post-service _ _ Half Leg MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Seg Pneumatic Appl Full MED202.060 Venous Ulcers E0667 Criteria. Submit for predetermination to avoid post-service _ _ Leg MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Seg Pneumatic Appl Full MED202.060 Venous Ulcers E0668 Criteria. Submit for predetermination to avoid post-service _ _ Arm MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 42/83 Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Seg Pneumatic Appli MED202.060 Venous Ulcers E0669 Criteria. Submit for predetermination to avoid post-service _ _ Half Leg MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Seg Pneum Int MED202.060 Venous Ulcers E0670 Criteria. Submit for predetermination to avoid post-service _ _ Legs/Trunk MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pressure Pneum Appl MED202.060 Venous Ulcers E0671 Criteria. Submit for predetermination to avoid post-service _ _ Full Leg MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pressure Pneum Appl MED202.060 Venous Ulcers E0672 Criteria. Submit for predetermination to avoid post-service _ _ Full Arm MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and MP Criteria: Procedure/service reviewed against Medical Policy Pressure Pneum Appl MED202.060 Venous Ulcers E0673 Criteria. Submit for predetermination to avoid post-service _ _ Half Leg MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for review. Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and EIU: Procedure/service not reimbursed by the Plan. Not subject Pneumatic Compression MED202.060 Venous Ulcers E0675 to pre-service review. Check EIU policy CPCP028, which is one _ _ Device MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for of our Clinical Payment and Coding Policy (CPCP). Venous Thromboembolism Prophylaxis Pneumatic Compression Pumps for Treatment of Lymphedema and Inter Limb Compress Unlisted: Procedure/service not specifically defined or MED202.060 Venous Ulcers E0676 _ _ Dev Nos classified, maybe subject to contract/clinical review. MED202.073 Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis MP Criteria: Procedure/service reviewed against Medical Policy E0691 Uvl Pnl 2 Sq Ft Or Less Criteria. Submit for predetermination to avoid post-service THE801.033 Phototherapy for Dermatologic Conditions _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E0692 Uvl Sys Panel 4 Ft Criteria. Submit for predetermination to avoid post-service THE801.033 Phototherapy for Dermatologic Conditions _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E0693 Uvl Sys Panel 6 Ft Criteria. Submit for predetermination to avoid post-service THE801.033 Phototherapy for Dermatologic Conditions _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E0694 Uvl Md Cabinet Sys 6 Ft Criteria. Submit for predetermination to avoid post-service THE801.033 Phototherapy for Dermatologic Conditions _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Conductive Garment Transcutaneous Electrical Stimulation (TENS) and Transcutaneous E0731 Criteria. Submit for predetermination to avoid post-service MED201.040 _ _ For Tens/ Electrical Modulation Pain Reprocessing (TEMPR) review. EIU: Procedure/service not reimbursed by the Plan. Not subject Pelvic Floor Stimulation (PFS) as a Treatment of Urinary or Fecal Non-Implant Pelv Flr E- DME101.037 E0740 to pre-service review. Check EIU policy CPCP028, which is one Incontinence _ _ Stim MED201.030 of our Clinical Payment and Coding Policy (CPCP). Sexual Dysfunctions, Assessment and Treatment MP Criteria: Procedure/service reviewed against Medical Neuromuscular Stim For SUR710.018 Sacral Nerve Neuromodulation/Stimulation E0745 Policy Criteria, may require Prior Authorization per contract _ _ Shock MED201.026 Surface Electrical Stimulation agreement. MP Criteria: Procedure/service reviewed against Medical Policy Elec Osteogen Stim Not E0747 Criteria. Submit for predetermination to avoid post-service SUR705.044 Electrical Bone Growth Stimulation of the Appendicular Skeleton _ _ Spine review. MP Criteria: Procedure/service reviewed against Medical Osteogen Ultrasound E0760 Policy Criteria, may require Prior Authorization per contract DME101.030 Low Intensity Pulsed Ultrasound Fracture Healing Device _ _ Stimltor agreement. MP Criteria: Procedure/service reviewed against Medical Policy Nontherm Electromgntc Electrostimulation and Electromagnetic Therapy for Treating E0761 Criteria. Submit for predetermination to avoid post-service MED201.027 _ _ Device Wounds review. EIU: Procedure/service not reimbursed by the Plan. Not subject Trans Elec Jt Stim Dev E0762 to pre-service review. Check EIU policy CPCP028, which is one MED201.042 Electrical Stimulation for the Treatment of Arthritis _ _ Sys of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Functional to pre-service review. Check EIU policy CPCP028, which is one E0764 MED201.033 Functional Neuromuscular Electrical Stimulation _ 6/30/2021 Neuromuscularstim of our Clinical Payment and Coding Policy (CPCP). May require Prior Authorization per contract agreement MP Criteria: Procedure/service reviewed against Medical Nerve Stimulator For Tx E0765 Policy Criteria, may require Prior Authorization per contract SUR709.031 Gastric Electrical Stimulation (GES) _ _ N&V agreement. MP Criteria: Procedure/service reviewed against Medical Policy Elec Stim Cancer E0766 Criteria. Submit for predetermination to avoid post-service MED201.039 Tumor Treating Fields (TTF) Therapy _ _ Treatment review. EIU: Procedure/service not reimbursed by the Plan. Not subject Electric Wound Electrostimulation and Electromagnetic Therapy for Treating E0769 to pre-service review. Check EIU policy CPCP028, which is one MED201.027 _ _ Treatment Dev Wounds of our Clinical Payment and Coding Policy (CPCP).

Unlisted: Procedure/service not specifically defined or Functional Electric Stim E0770 classified, maybe subject to contract/clinical review. May _ _ _ _ Nos require Prior Authorization per contract agreement.

EIU: Procedure/service not reimbursed by the Plan. Not subject Ambulatory Traction E0830 to pre-service review. Check EIU policy CPCP028, which is one DME101.041 Pneumatic Traction and Spinal Unloading Devices _ _ Device of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 43/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Tract Frame Attach E0840 to pre-service review. Check EIU policy CPCP028, which is one DME101.046 Traction Devices for Use in the Home _ _ Headboard of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cervical Pneum Trac DME101.041 Pneumatic Traction and Spinal Unloading Devices E0849 to pre-service review. Check EIU policy CPCP028, which is one _ _ Equip DME101.046 Traction Devices for Use in the Home of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Traction Stand Free E0850 to pre-service review. Check EIU policy CPCP028, which is one DME101.046 Traction Devices for Use in the Home _ _ Standing of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cervical Traction E0855 to pre-service review. Check EIU policy CPCP028, which is one DME101.046 Traction Devices for Use in the Home _ _ Equipment of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cervic Collar W Air DME101.041 Pneumatic Traction and Spinal Unloading Devices E0856 to pre-service review. Check EIU policy CPCP028, which is one _ _ Bladders DME101.046 Traction Devices for Use in the Home of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Tract Equip Cervical E0860 to pre-service review. Check EIU policy CPCP028, which is one DME101.046 Traction Devices for Use in the Home _ _ Tract of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Traction Frame Attach E0890 to pre-service review. Check EIU policy CPCP028, which is one DME101.046 Traction Devices for Use in the Home _ _ Pelvic of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Hd Trapeze Bar Attach E0911 Criteria. Submit for predetermination to avoid post-service DME101.001 Hospital Beds and Related Equipment _ _ To Bed review. MP Criteria: Procedure/service reviewed against Medical Policy Fracture Frame E0920 Criteria. Submit for predetermination to avoid post-service DME101.046 Traction Devices for Use in the Home _ _ Attached To B review. MP Criteria: Procedure/service reviewed against Medical Policy Fracture Frame Free E0930 Criteria. Submit for predetermination to avoid post-service DME101.046 Traction Devices for Use in the Home _ _ Standing review. MP Criteria: Procedure/service reviewed against Medical Policy Cont Pas Motion E0935 Criteria. Submit for predetermination to avoid post-service DME101.023 Continuous Passive Motion (CPM) Device _ _ Exercise Dev review. EIU: Procedure/service not reimbursed by the Plan. Not subject Cpm Device Other Than E0936 to pre-service review. Check EIU policy CPCP028, which is one DME101.023 Continuous Passive Motion (CPM) Device _ _ Knee of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cervical Head E0942 to pre-service review. Check EIU policy CPCP028, which is one DME101.046 Traction Devices for Use in the Home _ _ Harness/Halter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Pelvic E0944 to pre-service review. Check EIU policy CPCP028, which is one DME101.046 Traction Devices for Use in the Home _ _ Belt/Harness/Boot of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Fracture Frame Dual W E0946 Criteria. Submit for predetermination to avoid post-service DME101.046 Traction Devices for Use in the Home _ _ Cross review. MP Criteria: Procedure/service reviewed against Medical Policy E0950 Tray Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy W/C Lateral Thigh/Knee E0953 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Sup review. MP Criteria: Procedure/service reviewed against Medical Policy Foot Box Any Type E0954 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Each Foot review. MP Criteria: Procedure/service reviewed against Medical Policy E0955 Cushioned Headrest Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Narrowing E0969 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Device review. MP Criteria: Procedure/service reviewed against Medical Policy Seat Upholstery E0981 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Replacement review. MP Criteria: Procedure/service reviewed against Medical Policy Back Upholstery E0982 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Replacement review. MP Criteria: Procedure/service reviewed against Medical Policy E0983 Add Pwr Joystick Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E0984 Add Pwr Tiller Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy W/C Seat Lift E0985 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Mechanism review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 44/83 MP Criteria: Procedure/service reviewed against Medical Policy Man W/C Push-Rim E0986 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Powr System review. Manual Wheelchair MP Criteria: Procedure/service reviewed against Medical Policy Accessory Lever- E0988 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Activated Wheel Drive review. Pair MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Elevating E0990 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Leg Res review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Solid Seat E0992 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Insert review. MP Criteria: Procedure/service reviewed against Medical Policy E1002 Pwr Seat Tilt Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E1003 Pwr Seat Recline Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E1004 Pwr Seat Recline Mech Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E1005 Pwr Seat Recline Pwr Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pwr Seat Combo W/O E1006 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Shear review. MP Criteria: Procedure/service reviewed against Medical Policy Pwr Seat Combo E1007 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ W/Shear review. MP Criteria: Procedure/service reviewed against Medical Policy Pwr Seat Combo Pwr E1008 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Shear review. MP Criteria: Procedure/service reviewed against Medical Policy E1009 Add Mech Leg Elevation Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E1010 Add Pwr Leg Elevation Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Ctr Mount Pwr Elev Leg E1012 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Rest review. MP Criteria: Procedure/service reviewed against Medical Policy W/C Manual E1028 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Swingaway review. MP Criteria: Procedure/service reviewed against Medical Policy Patient Transfer System DME101.034 Lifts and Elevator Systems E1036 Criteria. Submit for predetermination to avoid post-service _ _ >299 DME101.010 Wheelchairs and Accessories review. MP Criteria: Procedure/service reviewed against Medical Policy Hemi-Wheelchair E1084 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Detachable A review. MP Criteria: Procedure/service reviewed against Medical Policy Hemi-Wheelchair Fixed E1085 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Arms review. MP Criteria: Procedure/service reviewed against Medical Policy Whchr S-Recl Fxd Arm E1100 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Leg Res review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Semi-Recl E1110 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Detach review. MP Criteria: Procedure/service reviewed against Medical Policy Whlchr Ampu Fxd Arm E1170 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Leg Rest review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Amputee E1171 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ W/O Leg R review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Amputee E1172 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Detach Ar review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Amputee E1180 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ W/ Foot R review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Amputee E1190 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ W/ Leg Re review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Amputee E1195 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Heavy Dut review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Spec Size W E1223 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Foot review. MP Criteria: Procedure/service reviewed against Medical Policy Manual Semi-Reclining E1225 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Back review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 45/83 MP Criteria: Procedure/service reviewed against Medical Policy Manual Fully Reclining E1226 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Back review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Spec Sz E1227 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Spec Ht A review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Spec Sz E1228 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Spec Ht B review. Pediatric Wheelchair Unlisted: Procedure/service not specifically defined or E1229 _ _ _ _ Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Power Operated E1230 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Vehicle review. MP Criteria: Procedure/service reviewed against Medical Policy Rigid Ped W/C Tilt-In- E1231 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Space review. Ped Power Wheelchair Unlisted: Procedure/service not specifically defined or E1239 DME101.010 Wheelchairs and Accessories _ _ Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Wheelchair Lightwt E1250 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Fixed Arm review. Durable Medical Unlisted: Procedure/service not specifically defined or E1399 _ _ _ _ Equipment Mi classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or E1699 Dialysis Equipment Noc _ _ _ _ classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Jaw Motion Rehab DME103.009 Mechanical Stretching Devices E1700 to pre-service review. Check EIU policy CPCP028, which is one _ _ System SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Repl Cushions For Jaw DME103.009 Mechanical Stretching Devices E1701 to pre-service review. Check EIU policy CPCP028, which is one _ _ Motion SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Repl Measr Scales Jaw DME103.009 Mechanical Stretching Devices E1702 to pre-service review. Check EIU policy CPCP028, which is one _ _ Motion SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD) of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Replacement Interface DME103.009 Mechanical Stretching Devices E1821 Criteria. Submit for predetermination to avoid post-service _ _ Spsd DME103.001 Orthotics review. MP Criteria: Procedure/service reviewed against Medical Policy Man W/Ch Acc Seat E2201 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ W>=20<23 review. MP Criteria: Procedure/service reviewed against Medical Policy E2202 Seat Width 24-27 In Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Frame Depth Less Than E2203 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ 22 In review. MP Criteria: Procedure/service reviewed against Medical Policy Frame Depth 22 To 25 E2204 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ In review. MP Criteria: Procedure/service reviewed against Medical Policy Man Wc Whl Lock E2206 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Comp Repl Ea review. Non Covered: Procedure/service not covered by the Plan. Not E2207 Crutch And Cane Holder _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy E2209 Arm Trough Each Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Propulsion E2211 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Tire review. MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Prop Tire E2212 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Tube review. MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Prop Tire E2213 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Insert review. MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Caster Tire E2214 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Each review. MP Criteria: Procedure/service reviewed against Medical Policy Pneumatic Caster Tire E2215 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Tube review. MP Criteria: Procedure/service reviewed against Medical Policy Foam Filled Propulsion E2216 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Tire review. MP Criteria: Procedure/service reviewed against Medical Policy Foam Filled Caster Tire E2217 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Each review. MP Criteria: Procedure/service reviewed against Medical Policy Foam Propulsion Tire E2218 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Each review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 46/83 MP Criteria: Procedure/service reviewed against Medical Policy Foam Caster Tire Any E2219 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Size Ea review. MP Criteria: Procedure/service reviewed against Medical Policy Solid Propuls Tire Repl E2220 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Ea review. MP Criteria: Procedure/service reviewed against Medical Policy Solid Caster Tire Repl E2221 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Each review. MP Criteria: Procedure/service reviewed against Medical Policy Solid Caster Integ Whl E2222 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Repl review. MP Criteria: Procedure/service reviewed against Medical Policy Mwc Acc Wheelchair E2228 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Brake review. MP Criteria: Procedure/service reviewed against Medical Policy Planar Back For Ped Size E2291 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wc review. MP Criteria: Procedure/service reviewed against Medical Policy Planar Seat For Ped Size E2292 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wc review. MP Criteria: Procedure/service reviewed against Medical Policy Contour Back For Ped E2293 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Size Wc review. MP Criteria: Procedure/service reviewed against Medical Policy Contour Seat For Ped E2294 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Size Wc review. Non Covered: Procedure/service not covered by the Plan. Not E2300 Pwr Seat Elevation Sys _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not E2301 Pwr Standing _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Electro Connect Btw E2310 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Control review. MP Criteria: Procedure/service reviewed against Medical Policy Electro Connect Btw 2 E2311 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Sys review. MP Criteria: Procedure/service reviewed against Medical Policy Mini-Prop Remote E2312 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Joystick review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Harness Expand E2313 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Control review. MP Criteria: Procedure/service reviewed against Medical Policy E2321 Hand Interface Joystick Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E2322 Mult Mech Switches Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E2323 Special Joystick Handle Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E2324 Chin Cup Interface Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E2325 Sip And Puff Interface Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy E2326 Breath Tube Kit Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Head Control Interface E2327 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Mech review. MP Criteria: Procedure/service reviewed against Medical Policy Head/Extremity Control E2328 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Inter review. MP Criteria: Procedure/service reviewed against Medical Policy Head Control E2329 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Nonproportional review. MP Criteria: Procedure/service reviewed against Medical Policy Head Control Proximity E2330 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Switc review. MP Criteria: Procedure/service reviewed against Medical Policy E2331 Attendant Control Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy W/C Wdth 20-23 In Seat E2340 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Frame review. MP Criteria: Procedure/service reviewed against Medical Policy W/C Wdth 24-27 In Seat E2341 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Frame review. MP Criteria: Procedure/service reviewed against Medical Policy W/C Dpth 20-21 In Seat E2342 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Frame review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 47/83 MP Criteria: Procedure/service reviewed against Medical Policy W/C Dpth 22-25 In Seat E2343 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Frame review. MP Criteria: Procedure/service reviewed against Medical Policy E2351 Electronic Sgd Interface Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. Power Wheelchair MP Criteria: Procedure/service reviewed against Medical Policy Accessory Group 34 E2358 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Non-Sealed Lead Acid review. Battery Each Power Wheelchair Accessory Group 34 MP Criteria: Procedure/service reviewed against Medical Policy Sealed Lead Acid E2359 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Battery Each (E.G. Gel review. Cell Absorbed Glassmat) MP Criteria: Procedure/service reviewed against Medical Policy 22Nf Nonsealed E2360 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Leadacid review. MP Criteria: Procedure/service reviewed against Medical Policy 22Nf Sealed Leadacid E2361 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Battery review. MP Criteria: Procedure/service reviewed against Medical Policy Gr24 Nonsealed E2362 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Leadacid review. MP Criteria: Procedure/service reviewed against Medical Policy Gr24 Sealed Leadacid E2363 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Battery review. MP Criteria: Procedure/service reviewed against Medical Policy U1Nonsealed Leadacid E2364 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Battery review. MP Criteria: Procedure/service reviewed against Medical Policy U1 Sealed Leadacid E2365 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Battery review. MP Criteria: Procedure/service reviewed against Medical Policy Battery Charger Single E2366 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Mode review. MP Criteria: Procedure/service reviewed against Medical Policy Battery Charger Dual E2367 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Mode review. MP Criteria: Procedure/service reviewed against Medical Policy Gr27 Sealed Leadacid E2371 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Battery review. MP Criteria: Procedure/service reviewed against Medical Policy Gr27 Non-Sealed E2372 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Leadacid review. MP Criteria: Procedure/service reviewed against Medical Policy Hand/Chin Ctrl Spec E2373 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Joystick review. MP Criteria: Procedure/service reviewed against Medical Policy Hand/Chin Ctrl Std E2374 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Joystick review. MP Criteria: Procedure/service reviewed against Medical Policy Non-Expandable E2375 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Controller review. MP Criteria: Procedure/service reviewed against Medical Policy Expandable Controller E2376 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Repl review. MP Criteria: Procedure/service reviewed against Medical Policy Expandable Controller E2377 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Initl review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Acc Lith-Based E2397 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Battery review. MP Criteria: Procedure/service reviewed against Medical Policy Sgd Digitized Pre-Rec E2500 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ <=8Min review. MP Criteria: Procedure/service reviewed against Medical Policy Sgd Prerec Msg >8Min E2502 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ <=20Min review. MP Criteria: Procedure/service reviewed against Medical Policy Sgd Prerec Msg>20Min E2504 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ <=40Min review. MP Criteria: Procedure/service reviewed against Medical Policy Sgd Prerec Msg > 40 E2506 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ Min review. MP Criteria: Procedure/service reviewed against Medical Policy Sgd Spelling Phys E2508 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ Contact review. MP Criteria: Procedure/service reviewed against Medical Policy Sgd W Multi Methods E2510 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ Msg/Accs review. MP Criteria: Procedure/service reviewed against Medical Policy Sgd Sftwre Prgrm For E2511 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ Pc/Pda review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 48/83 MP Criteria: Procedure/service reviewed against Medical Policy Sgd Accessory E2512 Criteria. Submit for predetermination to avoid post-service DME104.009 Speech Generating Devices (SGD) _ _ Mounting Sys review. Unlisted: Procedure/service not specifically defined or E2599 Sgd Accessory Noc DME104.009 Speech Generating Devices (SGD) _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Gen W/C Cushion Wdth E2601 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ < 22 In review. MP Criteria: Procedure/service reviewed against Medical Policy Gen W/C Cushion Wdth E2602 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ >=22 In review. MP Criteria: Procedure/service reviewed against Medical Policy Skin Protect Wc Cus Wd E2603 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ <22In review. MP Criteria: Procedure/service reviewed against Medical Policy Skin Protect Wc Cus E2604 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd>=22In review. MP Criteria: Procedure/service reviewed against Medical Policy Position Wc Cush Wdth E2605 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ <22 In review. MP Criteria: Procedure/service reviewed against Medical Policy Position Wc Cush E2606 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wdth>=22 In review. MP Criteria: Procedure/service reviewed against Medical Policy Skin Pro/Pos Wc Cus E2607 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd <22In review. MP Criteria: Procedure/service reviewed against Medical Policy Skin Pro/Pos Wc Cus E2608 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd>=22In review. MP Criteria: Procedure/service reviewed against Medical Policy Custom Fabricate W/C E2609 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Cushion review. MP Criteria: Procedure/service reviewed against Medical Policy Gen Use Back Cush E2611 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wdth <22In review. MP Criteria: Procedure/service reviewed against Medical Policy Gen Use Back Cush E2612 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wdth>=22In review. MP Criteria: Procedure/service reviewed against Medical Policy Position Back Cush Wd E2613 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ <22In review. MP Criteria: Procedure/service reviewed against Medical Policy Position Back Cush E2614 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd>=22In review. MP Criteria: Procedure/service reviewed against Medical Policy Pos Back Post/Lat Wdth E2615 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ <22In review. MP Criteria: Procedure/service reviewed against Medical Policy Pos Back Post/Lat E2616 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wdth>=22In review. MP Criteria: Procedure/service reviewed against Medical Policy Custom Fab W/C Back E2617 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Cushion review. MP Criteria: Procedure/service reviewed against Medical Policy Wc Planar Back Cush E2620 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd <22In review. MP Criteria: Procedure/service reviewed against Medical Policy Wc Planar Back Cush E2621 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd>=22In review. MP Criteria: Procedure/service reviewed against Medical Policy Adj Skin Pro W/C Cus E2622 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd<22In review. MP Criteria: Procedure/service reviewed against Medical Policy Adj Skin Pro Wc Cus E2623 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Wd>=22In review. MP Criteria: Procedure/service reviewed against Medical Policy Adj Skin Pro/Pos E2624 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Cus<22In review. MP Criteria: Procedure/service reviewed against Medical Policy Adj Skin Pro/Pos Wc E2625 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Cus>=21 review. Wheelchair Accessory Shoulder Elbow Mobile MP Criteria: Procedure/service reviewed against Medical Policy E2626 Arm Support Attached Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ To Wheelchair review. Balanced Adjustable

Wheelchair Accessory Shoulder Elbow Mobile MP Criteria: Procedure/service reviewed against Medical Policy Arm Support Attached E2627 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ To Wheelchair review. Balanced Adjustable Rancho Type

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 49/83 Wheelchair Accessory Shoulder Elbow Mobile MP Criteria: Procedure/service reviewed against Medical Policy E2628 Arm Support Attached Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ To Wheelchair review. Balanced Reclining

Wheelchair Accessory Shoulder Elbow Mobile Arm Support Attached MP Criteria: Procedure/service reviewed against Medical Policy To Wheelchair E2629 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Balanced Friction Arm review. Support (Friction Dampening To Proximal And Distal Joints)

Wheelchair Accessory Shoulder Elbow Mobile Arm Support Monosuspension Arm MP Criteria: Procedure/service reviewed against Medical Policy E2630 And Hand Support Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Overhead Elbow review. Forearm Hand Sling Support Yoke Type Suspension Support

Wheelchair Accessory MP Criteria: Procedure/service reviewed against Medical Policy Addition To Mobile Arm E2631 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Support Elevating review. Proximal Arm

Wheelchair Accessory Addition To Mobile Arm MP Criteria: Procedure/service reviewed against Medical Policy Support Offset Or E2632 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Lateral Rocker Arm review. With Elastic Balance Control

Wheelchair Accessory MP Criteria: Procedure/service reviewed against Medical Policy E2633 Addition To Mobile Arm Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Support Supinator review. MP Criteria: Procedure/service reviewed against Medical Policy Opps/Php;Activity G0176 Criteria. Submit for predetermination to avoid post-service PSY301.014 Autism Spectrum Disorders (ASD) _ _ Therapy review. Unlisted: Procedure/service not specifically defined or Pet Imaging Any Site G0235 classified, maybe subject to contract/clinical review. May AIM Guidelines _ _ _ Not Otherwise Specified require Prior Authorization per contract agreement.

EIU: Procedure/service not reimbursed by the Plan. Not subject Current Percep MED205.033 Automated Point-of-Care Nerve Conduction Testing G0255 to pre-service review. Check EIU policy CPCP028, which is one _ _ Threshold Tst MED205.030 Quantitative Sensory Testing of our Clinical Payment and Coding Policy (CPCP). Pild/Placebo Control Non Covered: Procedure/service not covered by the Plan. Not G0276 _ _ _ _ Clin Tr subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Hbot Full Body G0277 Policy Criteria, may require Prior Authorization per contract THE801.003 Hyperbaric Oxygen (HBO2) Therapy _ _ Chamber 30M agreement. EIU: Procedure/service not reimbursed by the Plan. Not subject Elec Stim Unattend For Electrostimulation and Electromagnetic Therapy for Treating G0281 to pre-service review. Check EIU policy CPCP028, which is one MED201.027 _ _ Press Wounds of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Elect Stim Wound Care Electrostimulation and Electromagnetic Therapy for Treating G0282 to pre-service review. Check EIU policy CPCP028, which is one MED201.027 _ _ Not Pd Wounds of our Clinical Payment and Coding Policy (CPCP). Non-Cov Surg Proc Clin Non Covered: Procedure/service not covered by the Plan. Not G0293 _ _ _ _ Trial subject to pre-service review. Non-Cov Proc Clinical Non Covered: Procedure/service not covered by the Plan. Not G0294 _ _ _ _ Trial subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Electrostimulation and Electromagnetic Therapy for Treating Electromagnetic MED201.027 G0295 to pre-service review. Check EIU policy CPCP028, which is one Wounds _ _ Therapy Onc THE803.008 of our Clinical Payment and Coding Policy (CPCP). Non Covered Physical Therapy Services MP Criteria: Procedure/service reviewed against Medical Policy Pre-Op Service Lvrs 10- G0303 Criteria. Submit for predetermination to avoid post-service THE803.025 Pulmonary Rehabilitation _ _ 15Dos review. EIU: Procedure/service not reimbursed by the Plan. Not subject Electrostimulation and Electromagnetic Therapy for Treating Electromagntic Tx For MED201.027 G0329 to pre-service review. Check EIU policy CPCP028, which is one Wounds _ _ Ulcers THE803.008 of our Clinical Payment and Coding Policy (CPCP). Non Covered Physical Therapy Services MP Criteria: Procedure/service reviewed against Medical Policy Percutaneous Islet G0341 Criteria. Submit for predetermination to avoid post-service SUR703.013 Pancreas and Related Organ Tissue Transplantation _ _ Celltrans review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 50/83 MP Criteria: Procedure/service reviewed against Medical Policy Laparoscopy Islet Cell G0342 Criteria. Submit for predetermination to avoid post-service SUR703.013 Pancreas and Related Organ Tissue Transplantation _ _ Trans review. MP Criteria: Procedure/service reviewed against Medical Policy Laparotomy Islet Cell G0343 Criteria. Submit for predetermination to avoid post-service SUR703.013 Pancreas and Related Organ Tissue Transplantation _ _ Transp review. Non Covered: Procedure/service not covered by the Plan. Not G0406 Inpt/Tele Follow Up 15 _ _ _ 12/31/2020 subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G0407 Inpt/Tele Follow Up 25 _ _ _ 12/31/2020 subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G0408 Inpt/Tele Follow Up 35 _ _ _ 12/31/2020 subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Prostate Biopsy Any Saturation Biopsy for Diagnosis, Staging and Management of G0416 Criteria. Submit for predetermination to avoid post-service SUR717.015 _ _ Mthd Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy review. MP Criteria: Procedure/service reviewed against Medical Policy Intens Cardiac Rehab G0422 Criteria. Submit for predetermination to avoid post-service THE803.023 Cardiac Rehabilitation (CR) _ _ W/Exerc review. MP Criteria: Procedure/service reviewed against Medical Policy Intens Cardiac Rehab G0423 Criteria. Submit for predetermination to avoid post-service THE803.023 Cardiac Rehabilitation (CR) _ _ No Exer review. Non Covered: Procedure/service not covered by the Plan. Not G0425 Inpt/Ed Teleconsult30 _ _ _ 12/31/2020 subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G0426 Inpt/Ed Teleconsult50 _ _ _ 12/31/2020 subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G0427 Inpt/Ed Teleconsult70 _ _ _ 12/31/2020 subject to pre-service review. Collagen Meniscus EIU: Procedure/service not reimbursed by the Plan. Not subject Implant Procedure For to pre-service review. Check EIU policy CPCP028, which is one G0428 Filling Meniscal Defects SUR705.034 Meniscal Allografts and Other Meniscal Implants _ _ of our Clinical Payment and Coding Policy (CPCP). May require (E.G. Cmi Collagen Prior Authorization per contract agreement Scaffold Menaflex) Dermal Filler Injection(S) For The Treatment Of Facial MP Criteria: Procedure/service reviewed against Medical Policy Lipodystrophy G0429 Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ Syndrome (Lds) (E.G. review. As A Result Of Highly Active Antiretroviral Therapy.) MP Criteria: Procedure/service reviewed against Medical Policy Fecal Microbiota Prep G0455 Criteria. Submit for predetermination to avoid post-service SUR703.049 Fecal Microbiota Transplantation (FMT) _ _ Instil review. Telehealth Inpt Pharm Non Covered: Procedure/service not covered by the Plan. Not G0459 _ _ _ 12/31/2020 Mgmt subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Autologous Prp For Recombinant and Autologous Platelet-Derived Growth Factors for G0460 to pre-service review. Check EIU policy CPCP028, which is one RX501.034 _ _ Ulcers Wound Healing and Other Non-Orthopedic Conditions of our Clinical Payment and Coding Policy (CPCP). Crit Care Telehea Non Covered: Procedure/service not covered by the Plan. Not G0508 _ _ _ 12/31/2020 Consult 60 subject to pre-service review. Crit Care Telehea Non Covered: Procedure/service not covered by the Plan. Not G0509 _ _ _ 12/31/2020 Consult 50 subject to pre-service review. Ccm/Bhi By Rhc/Fqhc Non Covered: Procedure/service not covered by the Plan. Not G0511 _ _ _ _ 20Min Mo subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Hormone Replacement Therapies (HRT) Using Implanted Pellets for Remove W Insert Drug RX501.007 G0518 Criteria. Submit for predetermination to avoid post-service Women and Delayed Puberty _ _ Implant RX501.082 review. Treatment of Opioid Dependence Alcohol/Sub Misuse Non Covered: Procedure/service not covered by the Plan. Not G2011 _ _ _ _ Assess subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G2058 Ccm Add 20Min _ _ _ 12/31/2020 subject to pre-service review. Md Mang High Risk Dx Non Covered: Procedure/service not covered by the Plan. Not G2064 _ _ _ _ 29 subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G2065 Clin Mang H Risk Dx 29 _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Visit Esketamine 56M G2082 Criteria. Submit for predetermination to avoid post-service RX501.105 Esketamine Nasal Spray _ 4/15/2021 Or Less review. MP Criteria: Procedure/service reviewed against Medical Policy Visit esketamine 56m or G2082 Criteria. Submit for predetermination to avoid post-service RX501.105 Esketamine Nasal Spray 08/01/2021 _ less review. MP Criteria: Procedure/service reviewed against Medical Policy G2083 Visit Esketamine > 56M Criteria. Submit for predetermination to avoid post-service RX501.105 Esketamine Nasal Spray _ 4/15/2021 review. MP Criteria: Procedure/service reviewed against Medical Policy G2083 Visit esketamine > 56m Criteria. Submit for predetermination to avoid post-service RX501.106 Esketamine Nasal Spray 08/01/2021 _ review. Lvef>=40% Doc Normal Non Covered: Procedure/service not covered by the Plan. Not G8395 _ _ _ _ Or Mild subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G8396 Lvef Not Performed _ _ _ _ subject to pre-service review. Dil Macula/Fundus Non Covered: Procedure/service not covered by the Plan. Not G8397 _ _ _ _ Exam/W Doc subject to pre-service review. Dil Macular/Fundus Not Non Covered: Procedure/service not covered by the Plan. Not G8398 _ _ _ 12/31/2020 Perfo subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 51/83 Pt W/Dxa Results Non Covered: Procedure/service not covered by the Plan. Not G8399 _ _ _ _ Document subject to pre-service review. Pt W/Dxa No Results Non Covered: Procedure/service not covered by the Plan. Not G8400 _ _ _ _ Doc subject to pre-service review. Low Extemity Neur Non Covered: Procedure/service not covered by the Plan. Not G8404 _ _ _ _ Exam Docum subject to pre-service review. Low Extemity Neur Not Non Covered: Procedure/service not covered by the Plan. Not G8405 _ _ _ _ Perfor subject to pre-service review. Eval On Foot Non Covered: Procedure/service not covered by the Plan. Not G8410 _ _ _ _ Documented subject to pre-service review. Eval On Foot Not Non Covered: Procedure/service not covered by the Plan. Not G8415 _ _ _ _ Performed subject to pre-service review. Pt Inelig Footwear Non Covered: Procedure/service not covered by the Plan. Not G8416 _ _ _ _ Evaluatio subject to pre-service review. Calc Bmi Abv Up Param Non Covered: Procedure/service not covered by the Plan. Not G8417 _ _ _ _ F/U subject to pre-service review. Calc Bmi Blw Low Non Covered: Procedure/service not covered by the Plan. Not G8418 _ _ _ _ Param F/U subject to pre-service review. Calc Bmi Out Nrm Non Covered: Procedure/service not covered by the Plan. Not G8419 _ _ _ _ Param Nof/U subject to pre-service review. Calc Bmi Norm Non Covered: Procedure/service not covered by the Plan. Not G8420 _ _ _ _ Parameters subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G8421 Bmi Not Calculated _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G8422 Pt Inelig Bmi Calculation _ _ _ _ subject to pre-service review. Docrev Cur Meds By Elig Non Covered: Procedure/service not covered by the Plan. Not G8427 _ _ _ _ Clin subject to pre-service review. Cur Meds Not Non Covered: Procedure/service not covered by the Plan. Not G8428 _ _ _ _ Document subject to pre-service review. Ec At Doc Medrec Pt Non Covered: Procedure/service not covered by the Plan. Not G8430 _ _ _ _ Not Elig subject to pre-service review. Pos Clin Depres Scrn Non Covered: Procedure/service not covered by the Plan. Not G8431 _ _ _ _ F/U Doc subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G8432 Dep Scr Not Doc Rng _ _ _ _ subject to pre-service review. Scr For Dep Not Cpt Doc Non Covered: Procedure/service not covered by the Plan. Not G8433 _ _ _ _ Rsn subject to pre-service review. Doc Pain As Nt Perf Not Non Covered: Procedure/service not covered by the Plan. Not G8442 _ _ _ 12/31/2020 Elg subject to pre-service review. Beta-Bloc Rx Pt W/Abn Non Covered: Procedure/service not covered by the Plan. Not G8450 _ _ _ _ Lvef subject to pre-service review. Pt W/Abn Lvef Inelig B- Non Covered: Procedure/service not covered by the Plan. Not G8451 _ _ _ _ Bloc subject to pre-service review. Pt W/Abn Lvef B-Bloc Non Covered: Procedure/service not covered by the Plan. Not G8452 _ _ _ _ No Rx subject to pre-service review. High Risk Recurrence Non Covered: Procedure/service not covered by the Plan. Not G8465 _ _ _ _ Pro Ca subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G8473 Ace/Arb Thxpy Rx?D _ _ _ _ subject to pre-service review. Ace/Arb Not Rx'D; Doc Non Covered: Procedure/service not covered by the Plan. Not G8474 _ _ _ _ Reas subject to pre-service review. Ace/Arb Thxpy Not Non Covered: Procedure/service not covered by the Plan. Not G8475 _ _ _ _ Rx?D subject to pre-service review. Bp Sys <140 And Dias Non Covered: Procedure/service not covered by the Plan. Not G8476 _ _ _ _ <89 subject to pre-service review. Bp Sys>=140 And/Or Non Covered: Procedure/service not covered by the Plan. Not G8477 _ _ _ _ Dias >=89 subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G8478 Bp Not Performed/Doc _ _ _ _ subject to pre-service review. Flu Immunize Non Covered: Procedure/service not covered by the Plan. Not G8482 _ _ _ _ Order/Admin subject to pre-service review. Flu Imm No Admin Doc Non Covered: Procedure/service not covered by the Plan. Not G8483 _ _ _ _ Rea subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G8484 Flu Immunize No Admin _ _ _ _ subject to pre-service review. Other Specified Case Unlisted: Procedure/service not specifically defined or G9012 _ _ _ _ Mgmt classified, maybe subject to contract/clinical review. Oncology Work-Up Non Covered: Procedure/service not covered by the Plan. Not G9050 _ _ _ _ Evaluation subject to pre-service review. Oncology Tx Decision- Non Covered: Procedure/service not covered by the Plan. Not G9051 _ _ _ _ Mgmt subject to pre-service review. Onc Surveillance For Non Covered: Procedure/service not covered by the Plan. Not G9052 _ _ _ _ Disease subject to pre-service review. Onc Expectant Non Covered: Procedure/service not covered by the Plan. Not G9053 _ _ _ _ Management Pt subject to pre-service review. Onc Supervision Non Covered: Procedure/service not covered by the Plan. Not G9054 _ _ _ _ Palliative subject to pre-service review. Onc Visit Unspecified Non Covered: Procedure/service not covered by the Plan. Not G9055 _ _ _ _ Nos subject to pre-service review. Onc Prac Mgmt Non Covered: Procedure/service not covered by the Plan. Not G9056 _ _ _ _ Adheres Guide subject to pre-service review. Onc Pract Mgmt Differs Non Covered: Procedure/service not covered by the Plan. Not G9057 _ _ _ _ Trial subject to pre-service review. Onc Prac Mgmt Non Covered: Procedure/service not covered by the Plan. Not G9058 _ _ _ _ Disagree W/Gui subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 52/83 Onc Prac Mgmt Pt Opt Non Covered: Procedure/service not covered by the Plan. Not G9059 _ _ _ _ Alterna subject to pre-service review. Onc Prac Mgmt Dif Pt Non Covered: Procedure/service not covered by the Plan. Not G9060 _ _ _ _ Comorb subject to pre-service review. Onc Prac Cond Noadd Non Covered: Procedure/service not covered by the Plan. Not G9061 _ _ _ _ By Guide subject to pre-service review. Onc Prac Guide Differs Non Covered: Procedure/service not covered by the Plan. Not G9062 _ _ _ _ Nos subject to pre-service review. Onc Dx Nsclc Stgi No Non Covered: Procedure/service not covered by the Plan. Not G9063 _ _ _ _ Progres subject to pre-service review. Onc Dx Nsclc Stg2 No Non Covered: Procedure/service not covered by the Plan. Not G9064 _ _ _ _ Progres subject to pre-service review. Onc Dx Nsclc Stg3A No Non Covered: Procedure/service not covered by the Plan. Not G9065 _ _ _ _ Progre subject to pre-service review. Onc Dx Nsclc Stg3B-4 Non Covered: Procedure/service not covered by the Plan. Not G9066 _ _ _ _ Metasta subject to pre-service review. Onc Dx Nsclc Dx Non Covered: Procedure/service not covered by the Plan. Not G9067 _ _ _ _ Unknown Nos subject to pre-service review. Onc Dx Sclc/Nsclc Non Covered: Procedure/service not covered by the Plan. Not G9068 _ _ _ _ Limited subject to pre-service review. Onc Dx Sclc/Nsclc Ext At Non Covered: Procedure/service not covered by the Plan. Not G9069 _ _ _ _ Dx subject to pre-service review. Onc Dx Sclc/Nsclc Ext Non Covered: Procedure/service not covered by the Plan. Not G9070 _ _ _ _ Unknwn subject to pre-service review. Onc Dx Brst Stg1-2B Hr Non Covered: Procedure/service not covered by the Plan. Not G9071 _ _ _ _ Nopro subject to pre-service review. Onc Dx Brst Stg1-2 Non Covered: Procedure/service not covered by the Plan. Not G9072 _ _ _ _ Noprogres subject to pre-service review. Onc Dx Brst Stg3-Hr No Non Covered: Procedure/service not covered by the Plan. Not G9073 _ _ _ _ Pro subject to pre-service review. Onc Dx Brst Stg3- Non Covered: Procedure/service not covered by the Plan. Not G9074 _ _ _ _ Noprogress subject to pre-service review. Onc Dx Brst Metastic/ Non Covered: Procedure/service not covered by the Plan. Not G9075 _ _ _ _ Recur subject to pre-service review. Onc Dx Prostate T1No Non Covered: Procedure/service not covered by the Plan. Not G9077 _ _ _ _ Progres subject to pre-service review. Onc Dx Prostate T2No Non Covered: Procedure/service not covered by the Plan. Not G9078 _ _ _ _ Progres subject to pre-service review. Onc Dx Prostate T3B- Non Covered: Procedure/service not covered by the Plan. Not G9079 _ _ _ _ T4Noprog subject to pre-service review. Onc Dx Prostate W/Rise Non Covered: Procedure/service not covered by the Plan. Not G9080 _ _ _ _ Psa subject to pre-service review. Onc Dx Prostate Non Covered: Procedure/service not covered by the Plan. Not G9083 _ _ _ _ Unknwn Nos subject to pre-service review. Onc Dx Colon T1-3 N1-2 Non Covered: Procedure/service not covered by the Plan. Not G9084 _ _ _ _ No Pr subject to pre-service review. Onc Dx Colon T4 N0 Non Covered: Procedure/service not covered by the Plan. Not G9085 _ _ _ _ W/O Prog subject to pre-service review. Onc Dx Colon T1-4 No Non Covered: Procedure/service not covered by the Plan. Not G9086 _ _ _ _ Dx Prog subject to pre-service review. Onc Dx Colon Metas Non Covered: Procedure/service not covered by the Plan. Not G9087 _ _ _ _ Evid Dx subject to pre-service review. Onc Dx Colon Metas Non Covered: Procedure/service not covered by the Plan. Not G9088 _ _ _ _ Noevid Dx subject to pre-service review. Onc Dx Colon Extent Non Covered: Procedure/service not covered by the Plan. Not G9089 _ _ _ _ Unknown subject to pre-service review. Onc Dx Rectal T1-2 No Non Covered: Procedure/service not covered by the Plan. Not G9090 _ _ _ _ Progr subject to pre-service review. Onc Dx Rectal T3 N0 No Non Covered: Procedure/service not covered by the Plan. Not G9091 _ _ _ _ Prog subject to pre-service review. Onc Dx Rectal T1-3 N1- Non Covered: Procedure/service not covered by the Plan. Not G9092 _ _ _ _ 2Noprg subject to pre-service review. Onc Dx Rectal T4 N M0 Non Covered: Procedure/service not covered by the Plan. Not G9093 _ _ _ _ No Prg subject to pre-service review. Onc Dx Rectal M1 Non Covered: Procedure/service not covered by the Plan. Not G9094 _ _ _ _ W/Mets Prog subject to pre-service review. Onc Dx Rectal Extent Non Covered: Procedure/service not covered by the Plan. Not G9095 _ _ _ _ Unknwn subject to pre-service review. Onc Dx Esophag T1-T3 Non Covered: Procedure/service not covered by the Plan. Not G9096 _ _ _ _ Noprog subject to pre-service review. Onc Dx Esophageal T4 Non Covered: Procedure/service not covered by the Plan. Not G9097 _ _ _ _ No Prog subject to pre-service review. Onc Dx Esophageal Non Covered: Procedure/service not covered by the Plan. Not G9098 _ _ _ _ Mets Recur subject to pre-service review. Onc Dx Esophageal Non Covered: Procedure/service not covered by the Plan. Not G9099 _ _ _ _ Unknown subject to pre-service review. Onc Dx Gastric No Non Covered: Procedure/service not covered by the Plan. Not G9100 _ _ _ _ Recurrence subject to pre-service review. Onc Dx Gastric P R1- Non Covered: Procedure/service not covered by the Plan. Not G9101 _ _ _ _ R2Noprog subject to pre-service review. Onc Dx Gastric Non Covered: Procedure/service not covered by the Plan. Not G9102 _ _ _ _ Unresectable subject to pre-service review. Onc Dx Gastric Non Covered: Procedure/service not covered by the Plan. Not G9103 _ _ _ _ Recurrent subject to pre-service review. Onc Dx Gastric Non Covered: Procedure/service not covered by the Plan. Not G9104 _ _ _ _ Unknown Nos subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 53/83 Onc Dx Pancreatc P R0 Non Covered: Procedure/service not covered by the Plan. Not G9105 _ _ _ _ Res No subject to pre-service review. Onc Dx Pancreatc P Non Covered: Procedure/service not covered by the Plan. Not G9106 _ _ _ _ R1/R2 No subject to pre-service review. Onc Dx Pancreatic Non Covered: Procedure/service not covered by the Plan. Not G9107 _ _ _ _ Unresectab subject to pre-service review. Onc Dx Pancreatic Non Covered: Procedure/service not covered by the Plan. Not G9108 _ _ _ _ Unknwn Nos subject to pre-service review. Onc Dx Head/Neck T1- Non Covered: Procedure/service not covered by the Plan. Not G9109 _ _ _ _ T2No Prg subject to pre-service review. Onc Dx Head/Neck T3-4 Non Covered: Procedure/service not covered by the Plan. Not G9110 _ _ _ _ Noprog subject to pre-service review. Onc Dx Head/Neck M1 Non Covered: Procedure/service not covered by the Plan. Not G9111 _ _ _ _ Mets Rec subject to pre-service review. Onc Dx Head/Neck Ext Non Covered: Procedure/service not covered by the Plan. Not G9112 _ _ _ _ Unknown subject to pre-service review. Onc Dx Ovarian Stg1A-B Non Covered: Procedure/service not covered by the Plan. Not G9113 _ _ _ _ No Pr subject to pre-service review. Onc Dx Ovarian Stg1A-B Non Covered: Procedure/service not covered by the Plan. Not G9114 _ _ _ _ Or 1 subject to pre-service review. Onc Dx Ovarian Stg3/4 Non Covered: Procedure/service not covered by the Plan. Not G9115 _ _ _ _ Noprog subject to pre-service review. Onc Dx Ovarian Non Covered: Procedure/service not covered by the Plan. Not G9116 _ _ _ _ Recurrence subject to pre-service review. Onc Dx Ovarian Non Covered: Procedure/service not covered by the Plan. Not G9117 _ _ _ _ Unknown Nos subject to pre-service review. Onc Dx Cml Chronic Non Covered: Procedure/service not covered by the Plan. Not G9123 _ _ _ _ Phase subject to pre-service review. Onc Dx Cml Acceler Non Covered: Procedure/service not covered by the Plan. Not G9124 _ _ _ _ Phase subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G9125 Onc Dx Cml Blast Phase _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not G9126 Onc Dx Cml Remission _ _ _ _ subject to pre-service review. Onc Dx Multi Myeloma Non Covered: Procedure/service not covered by the Plan. Not G9128 _ _ _ _ Stage I subject to pre-service review. Onc Dx Mult Myeloma Non Covered: Procedure/service not covered by the Plan. Not G9129 _ _ _ _ Stg2 Hig subject to pre-service review. Onc Dx Multi Myeloma Non Covered: Procedure/service not covered by the Plan. Not G9130 _ _ _ _ Unknown subject to pre-service review. Onc Dx Brst Unknown Non Covered: Procedure/service not covered by the Plan. Not G9131 _ _ _ _ Nos subject to pre-service review. Onc Dx Prostate Mets Non Covered: Procedure/service not covered by the Plan. Not G9132 _ _ _ _ No Cast subject to pre-service review. Onc Dx Prostate Clinical Non Covered: Procedure/service not covered by the Plan. Not G9133 _ _ _ _ Met subject to pre-service review. Onc Nhlstg 1-2 No Relap Non Covered: Procedure/service not covered by the Plan. Not G9134 _ _ _ _ No subject to pre-service review. Onc Dx Nhl Stg 3-4 Not Non Covered: Procedure/service not covered by the Plan. Not G9135 _ _ _ _ Relap subject to pre-service review. Onc Dx Nhl Trans To Lg Non Covered: Procedure/service not covered by the Plan. Not G9136 _ _ _ _ Bcell subject to pre-service review. Onc Dx Nhl Non Covered: Procedure/service not covered by the Plan. Not G9137 _ _ _ _ Relapse/Refractor subject to pre-service review. Onc Dx Nhl Stg Non Covered: Procedure/service not covered by the Plan. Not G9138 _ _ _ _ Unknown subject to pre-service review. Onc Dx Cml Dx Status Non Covered: Procedure/service not covered by the Plan. Not G9139 _ _ _ _ Unknown subject to pre-service review. Frontier Extended Stay Non Covered: Procedure/service not covered by the Plan. Not G9140 _ _ _ _ Demo subject to pre-service review.

Outpatient Intravenous Insulin Treatment (Oivit) Either Pulsatile Or Continuous By Any Means Guided By The Results Of Measurements EIU: Procedure/service not reimbursed by the Plan. Not subject G9147 For:Respiratory to pre-service review. Check EIU policy CPCP028, which is one MED201.028 Intermittent Intravenous Insulin Therapy _ _ Quotient; And/Or Urine of our Clinical Payment and Coding Policy (CPCP). Urea Nitrogen (Uun); And/Or Arterial Venous Or Capillary Glucose; And/Or Potassium Concentration Remote E/M New Pt Non Covered: Procedure/service not covered by the Plan. Not G9481 _ _ _ _ 10Mins subject to pre-service review. Remote E/M New Pt Non Covered: Procedure/service not covered by the Plan. Not G9482 _ _ _ _ 20Mins subject to pre-service review. Remote E/M New Pt Non Covered: Procedure/service not covered by the Plan. Not G9483 _ _ _ _ 30Mins subject to pre-service review. Remote E/M New Pt Non Covered: Procedure/service not covered by the Plan. Not G9484 _ _ _ _ 45Mins subject to pre-service review. Remote E/M New Pt Non Covered: Procedure/service not covered by the Plan. Not G9485 _ _ _ _ 60Mins subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 54/83 Remote E/M Est. Pt Non Covered: Procedure/service not covered by the Plan. Not G9486 _ _ _ _ 10Mins subject to pre-service review. Remote E/M Est. Pt Non Covered: Procedure/service not covered by the Plan. Not G9487 _ _ _ _ 15Mins subject to pre-service review. Remote E/M Est. Pt Non Covered: Procedure/service not covered by the Plan. Not G9488 _ _ _ _ 25Mins subject to pre-service review. Remote E/M Est. Pt Non Covered: Procedure/service not covered by the Plan. Not G9489 _ _ _ _ 40Mins subject to pre-service review. Mental Health Service Unlisted: Procedure/service not specifically defined or H0046 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Alcohol/Drug Abuse Svc Unlisted: Procedure/service not specifically defined or H0047 _ _ _ _ Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical RX501.113 Abatacept J0129 Abatacept Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Agalsidase Beta RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J0180 Policy Criteria, may require Prior Authorization per contract _ _ Injection RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical J0202 Injection Alemtuzumab Policy Criteria, may require Prior Authorization per contract RX501.077 Alemtuzumab _ _ agreement. Alglucosidase Alfa Unlisted: Procedure/service not specifically defined or J0220 RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders _ _ Injection classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Injection Alglucosidase RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J0221 Policy Criteria, may require Prior Authorization per contract _ _ Alfa (Lumizyme) 10 Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical J0222 Inj. patisiran 0.1 mg Policy Criteria, may require Prior Authorization per contract RX501.102 Patisiran (Onpattro) 7/1/2021 _ agreement. MP Criteria: Procedure/service reviewed against Medical RX501.125 Givosiran J0223 Inj Givosiran 0.5 Mg Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Policy J0224 Inj. lumasiran 0.5 mg Criteria. Submit for predetermination to avoid post-service N/A N/A 7/1/2021 _ review. Alpha 1 Proteinase Unlisted: Procedure/service not specifically defined or J0256 _ _ _ _ Inhibitor classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Injection Belimumab RX501.116 Belimumab J0490 Policy Criteria, may require Prior Authorization per contract _ _ 10 Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical RX501.100 Benralizumab J0517 Inj. Benralizumab 1 Mg Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Inj Bezlotoxumab 10 J0565 Policy Criteria, may require Prior Authorization per contract RX501.093 Bezlotoxumab (Zinplava) _ _ Mg agreement. MP Criteria: Procedure/service reviewed against Medical Inj. Cerliponase Alfa 1 J0567 Policy Criteria, may require Prior Authorization per contract RX501.092 Cerliponase alfa _ _ Mg agreement. MP Criteria: Procedure/service reviewed against Medical Injection Burosumab- RX502.058 Burosumab-twza J0584 Policy Criteria, may require Prior Authorization per contract _ _ Twza 1M RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Injection RX501.019 Botulinum Toxin J0585 Policy Criteria, may require Prior Authorization per contract _ _ Onabotulinumtoxina MED201.014 Treatment of Hyperhidrosis agreement. MP Criteria: Procedure/service reviewed against Medical RX501.019 Botulinum Toxin J0586 Abobotulinumtoxina Policy Criteria, may require Prior Authorization per contract _ _ MED201.014 Treatment of Hyperhidrosis agreement. MP Criteria: Procedure/service reviewed against Medical Inj RX501.019 Botulinum Toxin J0587 Policy Criteria, may require Prior Authorization per contract _ _ Rimabotulinumtoxinb MED201.014 Treatment of Hyperhidrosis agreement. Injection MP Criteria: Procedure/service reviewed against Medical RX501.019 Botulinum Toxin J0588 Incobotulinumtoxin A 1 Policy Criteria, may require Prior Authorization per contract _ _ MED201.014 Treatment of Hyperhidrosis Unit agreement. Inj Deoxycholic Acid 1 Non Covered: Procedure/service not covered by the Plan. Not J0591 _ _ _ _ Mg subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Management of Hereditary Angioedema (HAE) with C1 Esterase RX504.013 J0598 C-1 Esterase Cinryze Policy Criteria, may require Prior Authorization per contract Inhibitor, Human and Ecallantide _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical RX501.119 Canakinumab J0638 Canakinumab Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Certolizumab Pegol Inj RX501.111 Certolizumab Pegol J0717 Policy Criteria, may require Prior Authorization per contract _ _ 1Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Collagenase Clost Hist J0775 Policy Criteria, may require Prior Authorization per contract RX501.073 Clostridial Collagenase for Fibroproliferative Disorders _ _ Inj agreement. MP Criteria: Procedure/service reviewed against Medical Inj Crizanlizumab-Tmca RX501.126 Crizanlizumab-tmca J0791 Policy Criteria, may require Prior Authorization per contract 3/1/2021 _ 5Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Darbepoetin Alfa Non- J0881 Policy Criteria, may require Prior Authorization per contract RX501.069 Erythropoiesis-Stimulating Agents (ESAs) _ _ Esrd agreement. MP Criteria: Procedure/service reviewed against Medical J0885 Epoetin Alfa Non-Esrd Policy Criteria, may require Prior Authorization per contract RX501.069 Erythropoiesis-Stimulating Agents (ESAs) _ _ agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 55/83 MP Criteria: Procedure/service reviewed against Medical J0888 Epoetin Beta Non Esrd Policy Criteria, may require Prior Authorization per contract RX501.069 Erythropoiesis-Stimulating Agents (ESAs) _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj luspatercept-aamt J0896 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 08/01/2021 _ 0.25mg review. MP Criteria: Procedure/service reviewed against Medical Management of Hereditary Angioedema (HAE) with C1 Esterase RX504.013 J1290 Ecallantide Injection Policy Criteria, may require Prior Authorization per contract Inhibitor, Human and Ecallantide _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical RX501.066 Eculizumab J1300 Eculizumab Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Injection Edaravone 1 RX501.095 Edaravone J1301 Policy Criteria, may require Prior Authorization per contract _ _ Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Inj. Ravulizumab-Cwvz RX501.107 Ravulizumab-cwvz (Ultomiris) J1303 Policy Criteria, may require Prior Authorization per contract _ _ 10 Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J1322 Elosulfase Alfa Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Advanced Therapies for Pharmacologic Treatment of Pulmonary J1325 Epoprostenol Injection Policy Criteria, may require Prior Authorization per contract RX501.056 _ _ Hypertension agreement. MP Criteria: Procedure/service reviewed against Medical Policy J1427 Vitolarsen, 10 mg Criteria. Submit for predetermination to avoid post-service RX501.129 Vitolarsen 5/1/2021 _ review. MP Criteria: Procedure/service reviewed against Medical J1428 Inj Eteplirsen 10 Mg Policy Criteria, may require Prior Authorization per contract RX501.084 Eteplirsen _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy J1429 Inj Golodirsen 10 Mg Criteria. Submit for predetermination to avoid post-service RX501.122 Golodirsen _ _ review. MP Criteria: Procedure/service reviewed against Medical RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J1458 Galsulfase Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1459 Inj Ivig Privigen 500 Mg Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 agreement. Specialty Medication Administration Site of Care Injection, immune MP Criteria: Procedure/service reviewed against Medical Policy Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and J1554 globulin (asceniv), Criteria. Submit for predetermination to avoid post-service RX504.003 4/1/2021 _ Subcutaneous Ig [SCIG]) 500mg review. MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1555 Inj Cuvitru 100 Mg Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and Inj Imm Glob Bivigam RX504.003 J1556 Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ 500Mg RX501.096 agreement. Specialty Medication Administration Site of Care Injection Immune Globulin (Gammaplex) MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1557 Intravenous Non- Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 Lyophilized (E.G. Liquid) agreement. Specialty Medication Administration Site of Care 500 Mg MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1558 Inj. Xembify 100 Mg Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1559 Hizentra Injection Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1561 Gamunex-C/Gammaked Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and J1562 Vivaglobin Inj Policy Criteria, may require Prior Authorization per contract RX504.003 _ _ Subcutaneous Ig [SCIG]) agreement. MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and Immune Globulin RX504.003 J1566 Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ Powder RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1568 Octagam Injection Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and Gammagard Liquid RX504.003 J1569 Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ Injection RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and RX504.003 J1572 Flebogamma Injection Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and Hyqvia 100Mg RX504.003 J1575 Policy Criteria, may require Prior Authorization per contract Subcutaneous Ig [SCIG]) _ _ Immuneglobulin RX501.096 agreement. Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Ivig Non-Lyophilized Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and J1599 Policy Criteria, may require Prior Authorization per contract RX504.003 _ _ Nos Subcutaneous Ig [SCIG]) agreement. MP Criteria: Procedure/service reviewed against Medical Golimumab For Iv Use RX501.112 Golimumab J1602 Policy Criteria, may require Prior Authorization per contract _ _ 1Mg RX501.096 Specialty Medication Administration Site of Care agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 56/83 MP Criteria: Procedure/service reviewed against Medical Policy Gonadorelin Hydroch/ Gonadotropin-Releasing Hormone (GnRH) Agonists and J1620 Criteria. Submit for predetermination to avoid post-service RX501.041 _ _ 100 Mcg Antagonists review. MP Criteria: Procedure/service reviewed against Medical Policy J1632 Inj. Brexanolone 1 Mg Criteria. Submit for predetermination to avoid post-service RX501.106 Brexanolone for Postpartum Depression _ _ review. MP Criteria: Procedure/service reviewed against Medical Gonadotropin-Releasing Hormone (GnRH) Agonists and J1675 Histrelin Acetate Policy Criteria, may require Prior Authorization per contract RX501.041 _ _ Antagonists agreement. MP Criteria: Procedure/service reviewed against Medical Progesterone Therapy as a Technique to Reduce Preterm Delivery J1726 Makena 10 Mg Policy Criteria, may require Prior Authorization per contract RX501.062 _ _ in High-Risk Pregnancies agreement. Inj Hydroxyprogst Unlisted: Procedure/service not specifically defined or Progesterone Therapy as a Technique to Reduce Preterm Delivery J1729 RX501.062 _ _ Capoat Nos classified, maybe subject to contract/clinical review. in High-Risk Pregnancies MP Criteria: Procedure/service reviewed against Medical RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J1743 Idursulfase Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical THE801.028 Acne Management Infliximab Not Biosimil J1745 Policy Criteria, may require Prior Authorization per contract RX501.051 Infliximab and Associated Biosimilars _ _ 10Mg agreement. RX501.096 Specialty Medication Administration Site of Care MP Criteria: Procedure/service reviewed against Medical Inj. Ibalizumab-Uiyk 10 RX501.099 Ibalizumab-uiyk (Trogarzo) J1746 Policy Criteria, may require Prior Authorization per contract _ _ Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J1786 Imuglucerase Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj. Inebilizumab-Cdon J1823 Criteria. Submit for predetermination to avoid post-service RX501.127 Oncology Medications 3/1/2021 _ 1 Mg review. MP Criteria: Procedure/service reviewed against Medical RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J1931 Laronidase Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Leuprolide Acetate Gonadotropin-Releasing Hormone (GnRH) Agonists and J1950 Policy Criteria, may require Prior Authorization per contract RX501.041 _ _ /3.75 Mg Antagonists agreement. MP Criteria: Procedure/service reviewed against Medical Policy Gonadotropin-Releasing Hormone (GnRH) Agonists and J1951 Inj fensolvi 0.25 mg Criteria. Submit for predetermination to avoid post-service RX501.041 7/1/2021 _ Antagonists review. MP Criteria: Procedure/service reviewed against Medical Injection Mepolizumab RX501.080 Mepolizumab J2182 Policy Criteria, may require Prior Authorization per contract _ _ 1Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical J2278 Ziconotide Injection Policy Criteria, may require Prior Authorization per contract RX501.060 Ziconotide _ _ agreement. MP Criteria: Procedure/service reviewed against Medical RX501.059 Natalizumab J2323 Natalizumab Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical J2326 Inj Nusinersen 0.1Mg Policy Criteria, may require Prior Authorization per contract RX501.086 Nusinersen _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Injection Ocrelizumab RX501.085 Ocrelizumab J2350 Policy Criteria, may require Prior Authorization per contract _ _ 1 Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical RX501.058 Omalizumab J2357 Omalizumab Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Inj Pasireotide Long J2502 Policy Criteria, may require Prior Authorization per contract RX501.079 Pasireotide _ _ Acting agreement. Intravitreal Angiogenesis Inhibitors for Retinal Vascular Disorders MP Criteria: Procedure/service reviewed against Medical Policy OTH903.027 Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Pegaptanib Sodium J2503 Criteria. Submit for predetermination to avoid post-service OTH903.020 Conditions _ _ Injection review. OTH903.015 Photodynamic Therapy (PDT) for Choroidal Neovascularization (CNV) MP Criteria: Procedure/service reviewed against Medical Injection Pegloticase 1 RX501.120 Pegloticase J2507 Policy Criteria, may require Prior Authorization per contract _ _ Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical J2562 Plerixafor Injection Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Injection Reslizumab RX501.083 Reslizumab J2786 Policy Criteria, may require Prior Authorization per contract _ _ 1Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J2840 Inj Sebelipase Alfa 1 Mg Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical J2860 Injection Siltuximab Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Inj. Eptinezumab-Jjmr 1 RX501.124 Eptinezumab-jjmr J3032 Policy Criteria, may require Prior Authorization per contract _ _ Mg RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Inj Taliglucerace Alfa 10 RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J3060 Policy Criteria, may require Prior Authorization per contract _ _ U RX501.096 Specialty Medication Administration Site of Care agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 57/83 MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery Inj Testostero SUR717.001 J3121 Policy Criteria, may require Prior Authorization per contract with Related Services _ _ Enanthate 1Mg RX501.076 agreement. Testosterone Replacement Therapies MP Criteria: Procedure/service reviewed against Medical Gender Assignment Surgery and Gender Reassignment Surgery Testosterone SUR717.001 J3145 Policy Criteria, may require Prior Authorization per contract with Related Services _ _ Undecanoate 1Mg RX501.076 agreement. Testosterone Replacement Therapies MP Criteria: Procedure/service reviewed against Medical Inj. Teprotumumab- RX501.096 Specialty Medication Administration Site of Care J3241 Policy Criteria, may require Prior Authorization per contract _ _ Trbw 10 Mg RX501.110 Teprotumumab agreement. MP Criteria: Procedure/service reviewed against Medical Inj. Tildrakizumab 1 RX501.096 Specialty Medication Administration Site of Care J3245 Policy Criteria, may require Prior Authorization per contract _ _ Mg RX501.123 Tildrakizumab-asmn agreement. MP Criteria: Procedure/service reviewed against Medical RX501.096 Specialty Medication Administration Site of Care J3262 Tocilizumab Injection Policy Criteria, may require Prior Authorization per contract _ _ RX501.115 Tocilizumab agreement. MP Criteria: Procedure/service reviewed against Medical Advanced Therapies for Pharmacologic Treatment of Pulmonary J3285 Treprostinil Injection Policy Criteria, may require Prior Authorization per contract RX501.056 _ _ Hypertension agreement. Triamcinolone Acet Inj Unlisted: Procedure/service not specifically defined or J3301 _ _ _ 05/04/2021 Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical J3315 Triptorelin Pamoate Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy Gonadotropin-Releasing Hormone (GnRH) Agonists and Inj. Triptorelin Xr 3.75 RX501.041 J3316 Criteria. Submit for predetermination to avoid post-service Antagonists _ _ Mg RX501.040 review. Human Growth Hormone (GH) MP Criteria: Procedure/service reviewed against Medical Ustekinumab Iv Inject RX501.096 Specialty Medication Administration Site of Care J3358 Policy Criteria, may require Prior Authorization per contract _ _ 1 Mg RX501.114 Ustekinumab agreement. MP Criteria: Procedure/service reviewed against Medical RX501.096 Specialty Medication Administration Site of Care J3380 Injection Vedolizumab Policy Criteria, may require Prior Authorization per contract _ _ RX501.117 Vedolizumab agreement. MP Criteria: Procedure/service reviewed against Medical RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J3385 Velaglucerase Alfa Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Policy Photodynamic Therapy (PDT) for Choroidal Neovascularization J3396 Verteporfin Injection Criteria. Submit for predetermination to avoid post-service OTH903.015 _ _ (CNV) review. MP Criteria: Procedure/service reviewed against Medical Inj. Vestronidase Alfa- RX501.067 Enzyme-Replacement Therapy for Lysosomal Storage Disorders J3397 Policy Criteria, may require Prior Authorization per contract _ _ Vjbk RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Inj Luxturna 1 Billion J3398 Policy Criteria, may require Prior Authorization per contract RX501.098 Gene Therapy for Inherited Retinal Dystrophy _ _ Vec G agreement. MP Criteria: Procedure/service reviewed against Medical Inj Onase Abepar-Xioi J3399 Policy Criteria, may require Prior Authorization per contract RX501.104 Zolgensma (onasemnogene abeparvovec-xioi) _ _ Treat agreement. Drugs Unclassified Unlisted: Procedure/service not specifically defined or J3490 _ _ _ _ Injection classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Edetate Disodium Per J3520 Criteria. Submit for predetermination to avoid post-service THE801.008 Chelation Therapy _ _ 150 Mg review. Laetrile Amygdalin Vit Non Covered: Procedure/service not covered by the Plan. Not J3570 _ _ _ _ B16 subject to pre-service review. Unlisted: Procedure/service not specifically defined or J3590 Unclassified Biologics _ _ _ _ classified, maybe subject to contract/clinical review. Esrd On Dialysi Drug/Bio Unlisted: Procedure/service not specifically defined or J3591 _ _ _ _ Noc classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy J7177 Inj. Fibryga 1 Mg Criteria. Submit for predetermination to avoid post-service RX501.072 Human Fibrinogen Concentrate (RiaSTAP and Fibryga) _ _ review. MP Criteria: Procedure/service reviewed against Medical Inj Human Fibrinogen J7178 Policy Criteria, may require Prior Authorization per contract RX501.072 Human Fibrinogen Concentrate (RiaSTAP and Fibryga) _ _ Con Nos agreement. Factor Viii Recombinant Unlisted: Procedure/service not specifically defined or J7192 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Factor Ix Recombinant Unlisted: Procedure/service not specifically defined or J7195 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Hemophilia Clot Factor Unlisted: Procedure/service not specifically defined or J7199 _ _ _ _ Noc classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Methyl Aminolevulinate J7309 Criteria. Submit for predetermination to avoid post-service THE801.027 Dermatologic Applications of Photodynamic Therapy (PDT) _ _ Top review. MP Criteria: Procedure/service reviewed against Medical Policy Inj Ocriplasmin 0.125 J7316 Criteria. Submit for predetermination to avoid post-service OTH903.026 Ocriplasmin for Symptomatic Vitreomacular Adhesion _ _ Mg review. MP Criteria: Procedure/service reviewed against Medical Carbidopa Levodopa Levodopa-Carbidopa Enteral Suspension (e.g. Duopa) for The J7340 Policy Criteria, may require Prior Authorization per contract RX504.015 _ _ Ent 100Ml Treatment of Parkinson Disease. agreement. Immunosuppressive Unlisted: Procedure/service not specifically defined or J7599 _ _ _ _ Drug Noc classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Acetylcysteine Comp J7604 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 58/83 EIU: Procedure/service not reimbursed by the Plan. Not subject J7607 Levalbuterol Comp Con to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7609 Albuterol Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7610 Albuterol Comp Con to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7615 Levalbuterol Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Beclomethasone Comp J7622 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Betamethasone Comp J7624 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7627 Budesonide Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bitolterol Mesylate J7628 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Comp Con of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bitolterol Mesylate J7629 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Comp Unt of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cromolyn Sodium Comp J7632 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7634 Budesonide Comp Con to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7635 Atropine Comp Con to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7636 Atropine Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Dexamethasone Comp J7637 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Con of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Dexamethasone Comp J7638 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7640 Formoterol Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7641 Flunisolide Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Glycopyrrolate Comp J7642 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Con of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Glycopyrrolate Comp J7643 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Ipratropium Bromide J7645 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Comp of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7647 Isoetharine Comp Con to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 59/83 EIU: Procedure/service not reimbursed by the Plan. Not subject J7650 Isoetharine Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Isoproterenol Comp J7657 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Con of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Isoproterenol Comp J7660 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Metaproterenol Comp J7667 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Con of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Metaproterenol Comp J7670 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Pentamidine Comp Unit J7676 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Dose of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Terbutaline Sulf Comp J7680 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Con of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Terbutaline Sulf Comp J7681 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Triamcinolone Comp J7683 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Con of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Triamcinolone Comp J7684 to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ Unit of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject J7685 Tobramycin Comp Unit to pre-service review. Check EIU policy CPCP028, which is one RX501.063 Compounded Drug Products _ _ of our Clinical Payment and Coding Policy (CPCP). Inhalation Solution For Unlisted: Procedure/service not specifically defined or J7699 _ _ _ _ Dme classified, maybe subject to contract/clinical review. Non-Inhalation Drug For Unlisted: Procedure/service not specifically defined or J7799 _ _ _ _ Dme classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or J7999 Compounded Drug Noc _ _ _ _ classified, maybe subject to contract/clinical review. Antiemetic Rectal/Supp Unlisted: Procedure/service not specifically defined or J8498 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Oral Prescrip Drug Non Unlisted: Procedure/service not specifically defined or J8499 _ _ _ _ Chemo classified, maybe subject to contract/clinical review. Antiemetic Drug Oral Unlisted: Procedure/service not specifically defined or J8597 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Oral Prescription Drug Unlisted: Procedure/service not specifically defined or J8999 _ _ _ _ Chemo classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or J9020 Asparaginase Nos _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical J9022 Inj Atezolizumab 10 Mg Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Injection Avelumab 10 J9023 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Mg agreement. MP Criteria: Procedure/service reviewed against Medical Injection Belinostat J9032 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ 10Mg agreement. Intravitreal Angiogenesis Inhibitors for Retinal Vascular Disorders MP Criteria: Procedure/service reviewed against Medical OTH903.027 Intravitreal Angiogenesis Inhibitors for Choroidal Vascular J9035 Bevacizumab Injection Policy Criteria, may require Prior Authorization per contract OTH903.020 Conditions _ _ agreement. OTH903.015 Photodynamic Therapy (PDT) for Choroidal Neovascularization (CNV)

Injection, belantamab MP Criteria: Procedure/service reviewed against Medical Policy J9037 mafodontin-blmg, Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 4/1/2021 _ 0.5mg review. MP Criteria: Procedure/service reviewed against Medical Injection J9039 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Blinatumomab agreement. MP Criteria: Procedure/service reviewed against Medical Injection Cabazitaxel 1 J9043 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Mg agreement. Inj Bortezomib Nos Unlisted: Procedure/service not specifically defined or J9044 _ _ _ _ 0.1 Mg classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 60/83 MP Criteria: Procedure/service reviewed against Medical Injection Carfilzomib 1 J9047 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Mg agreement. MP Criteria: Procedure/service reviewed against Medical J9057 Inj. Copanlisib 1 Mg Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj. Cemiplimab-Rwlc 1 J9119 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ Mg review. MP Criteria: Procedure/service reviewed against Medical Policy Daratumumab J9144 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 2/1/2021 _ Hyaluronidase review. MP Criteria: Procedure/service reviewed against Medical Injection J9145 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Daratumumab 10 Mg agreement. MP Criteria: Procedure/service reviewed against Medical Inj Daunorubicin J9153 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Cytarabine agreement. MP Criteria: Procedure/service reviewed against Medical J9155 Degarelix Injection Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical J9173 Inj. Durvalumab 10 Mg Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Injection Elotuzumab J9176 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ 1Mg agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj Enfort Vedo-Ejfv J9177 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ 0.25Mg review. MP Criteria: Procedure/service reviewed against Medical Goserelin Acetate Gonadotropin-Releasing Hormone (GnRH) Agonists and J9202 Policy Criteria, may require Prior Authorization per contract RX501.041 _ _ Implant Antagonists agreement. MP Criteria: Procedure/service reviewed against Medical Gemtuzumab J9203 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Ozogamicin 0.1 Mg agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj Mogamulizumab- J9204 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ Kpkc 1 Mg review. MP Criteria: Procedure/service reviewed against Medical Inj Irinotecan Liposome J9205 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ 1 Mg agreement. MP Criteria: Procedure/service reviewed against Medical Leuprolide Acetate Gonadotropin-Releasing Hormone (GnRH) Agonists and J9217 Policy Criteria, may require Prior Authorization per contract RX501.041 _ _ Suspnsion Antagonists agreement. MP Criteria: Procedure/service reviewed against Medical Leuprolide Acetate Gonadotropin-Releasing Hormone (GnRH) Agonists and J9219 Policy Criteria, may require Prior Authorization per contract RX501.041 _ _ Implant Antagonists agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj. Lurbinectedin 0.1 J9223 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 2/1/2021 _ Mg review. MP Criteria: Procedure/service reviewed against Medical J9225 Vantas Implant Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Gonadotropin-Releasing Hormone (GnRH) Agonists and J9226 Supprelin La Implant Policy Criteria, may require Prior Authorization per contract RX501.041 _ _ Antagonists agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj. Isatuximab-Irfc 10 J9227 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ Mg review. MP Criteria: Procedure/service reviewed against Medical Injection Ipilimumab 1 J9228 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Mg agreement. MP Criteria: Procedure/service reviewed against Medical Inj Inotuzumab Ozogam J9229 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ 0.1 Mg agreement. MP Criteria: Procedure/service reviewed against Medical Paclitaxel Protein J9264 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Bound agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj. Tagraxofusp-Erzs 10 J9269 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ Mcg review. MP Criteria: Procedure/service reviewed against Medical J9271 Inj Pembrolizumab Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy J9281 Mitomycin Instillation Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 2/1/2021 _ review. Non Covered: Procedure/service not covered by the Plan. Not J9285 Inj Olaratumab 10 Mg _ _ 5/15/2021 _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical J9285 Inj Olaratumab 10 Mg Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Injection Necitumumab J9295 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ 1 Mg agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 61/83 MP Criteria: Procedure/service reviewed against Medical J9299 Injection Nivolumab Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical J9301 Obinutuzumab Inj Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Injection Pertuzumab J9306 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ 1 Mg agreement. MP Criteria: Procedure/service reviewed against Medical J9308 Injection Ramucirumab Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj Polatuzumab J9309 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ Vedotin 1Mg review. MP Criteria: Procedure/service reviewed against Medical Inj Rituximab J9311 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Hyaluronidase agreement. MP Criteria: Procedure/service reviewed against Medical J9312 Inj. Rituximab 10 Mg Policy Criteria, may require Prior Authorization per contract RX502.030 Rituximab and Biosimilars for Non-Oncologic Indications _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy J9313 Inj. Lumoxiti 0.01 Mg Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ review. Injection, pertuzumab, MP Criteria: Procedure/service reviewed against Medical Policy trastuzumab, and J9316 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 5/1/2021 _ hyaluronidase-zzxf, per review. 10 mg MP Criteria: Procedure/service reviewed against Medical Policy Sacituzumab Govitecan- J9317 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 2/1/2021 _ Hziy review. MP Criteria: Procedure/service reviewed against Medical Policy Injection, sacituzumab J9317 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 2/1/2021 _ govitecan-hziy, 2.5 mg review. MP Criteria: Procedure/service reviewed against Medical Inj Talimogene J9325 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Laherparepvec agreement. MP Criteria: Procedure/service reviewed against Medical Policy Injection, tafasitamab- J9349 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 4/1/2021 _ cxix, 2mg review. MP Criteria: Procedure/service reviewed against Medical Injection Trabectedin J9352 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ 0.1Mg agreement. MP Criteria: Procedure/service reviewed against Medical Inj Ado-Trastuzumab J9354 Policy Criteria, may require Prior Authorization per contract RX502.061 Oncology Medications _ _ Emt 1Mg agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj Fam-Trastu Deru- J9358 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 2/1/2021 _ Nxki 1Mg review. MP Criteria: Procedure/service reviewed against Medical Policy Porfimer Sodium Oncologic Applications of Photodynamic Therapy, Including Barrett J9600 Criteria. Submit for predetermination to avoid post-service THE801.029 _ _ Injection Esophagus review. Unlisted: Procedure/service not specifically defined or J9999 Chemotherapy Drug _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Stnd Wt Frame Power K0010 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Whlchr review. MP Criteria: Procedure/service reviewed against Medical Policy Stnd Wt Pwr Whlchr W K0011 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Control review. MP Criteria: Procedure/service reviewed against Medical Policy Ltwt Portbl Power K0012 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Whlchr review. MP Criteria: Procedure/service reviewed against Medical Policy Custom Power Whlchr K0013 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Base review. MP Criteria: Procedure/service reviewed against Medical Policy Other Power Whlchr K0014 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Base review. MP Criteria: Procedure/service reviewed against Medical Policy Elevate Footrest K0053 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Articulate review. MP Criteria: Procedure/service reviewed against Medical Policy Seat Ht <17 Or >=21 K0056 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Ltwt Wc review. W/C Component- Unlisted: Procedure/service not specifically defined or K0108 DME101.010 Wheelchairs and Accessories _ _ Accessory Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Pump Uninterrupted Advanced Therapies for Pharmacologic Treatment of Pulmonary K0455 Criteria. Submit for predetermination to avoid post-service RX501.056 _ _ Infusion Hypertension review. MP Criteria: Procedure/service reviewed against Medical Policy Seat/Back Cus No K0669 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Dmepdac Ver review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 62/83 Suction Pump Home MP Criteria: Procedure/service reviewed against Medical Policy Negative Pressure Wound Therapy (NPWT) for the Treatment of K0743 Model Portable For Criteria. Submit for predetermination to avoid post-service DME101.036 _ _ Wounds Use On Wounds review. Absorptive Wound Dressing For Use With MP Criteria: Procedure/service reviewed against Medical Policy Suction Pump Home Negative Pressure Wound Therapy (NPWT) for the Treatment of K0744 Criteria. Submit for predetermination to avoid post-service DME101.036 _ _ Model Portable Pad Wounds review. Size 16 Square Inches Or Less

Absorptive Wound Dressing For Use With Suction Pump Home MP Criteria: Procedure/service reviewed against Medical Policy Model Portable Pad Negative Pressure Wound Therapy (NPWT) for the Treatment of K0745 Criteria. Submit for predetermination to avoid post-service DME101.036 _ _ Size More Than 16 Wounds review. Square Inches But Less Than Or Equal To 48 Square Inches

Absorptive Wound Dressing For Use With MP Criteria: Procedure/service reviewed against Medical Policy Suction Pump Home Negative Pressure Wound Therapy (NPWT) for the Treatment of K0746 Criteria. Submit for predetermination to avoid post-service DME101.036 _ _ Model Portable Pad Wounds review. Size Greater Than 48 Square Inches MP Criteria: Procedure/service reviewed against Medical Policy Pov Group 1 Std Up To K0800 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ 300Lbs review. MP Criteria: Procedure/service reviewed against Medical Policy Pov Group 1 Hd 301- K0801 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ 450 Lbs review. MP Criteria: Procedure/service reviewed against Medical Policy Pov Group 1 Vhd 451- K0802 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ 600 Lbs review. MP Criteria: Procedure/service reviewed against Medical Policy Pov Group 2 Std Up To K0806 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ 300Lbs review. MP Criteria: Procedure/service reviewed against Medical Policy Pov Group 2 Hd 301- K0807 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ 450 Lbs review. MP Criteria: Procedure/service reviewed against Medical Policy Pov Group 2 Vhd 451- K0808 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ 600 Lbs review. Power Operated Unlisted: Procedure/service not specifically defined or K0812 DME101.010 Wheelchairs and Accessories _ _ Vehicle Noc classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 1 Std Port K0813 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Seat/Back review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 1 Std Port Cap K0814 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Chair review. MP Criteria: Procedure/service reviewed against Medical Policy K0815 Pwc Gp 1 Std Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0816 Pwc Gp 1 Std Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 2 Std Port K0820 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Seat/Back review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 2 Std Port Cap K0821 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Chair review. MP Criteria: Procedure/service reviewed against Medical Policy K0822 Pwc Gp 2 Std Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0823 Pwc Gp 2 Std Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0824 Pwc Gp 2 Hd Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0825 Pwc Gp 2 Hd Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 2 Vhd K0826 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Seat/Back review. MP Criteria: Procedure/service reviewed against Medical Policy K0827 Pwc Gp Vhd Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 2 Xtra Hd K0828 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Seat/Back review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 63/83 MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 2 Xtra Hd Cap K0829 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Chair review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Std Seat K0830 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Elevate S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Std Seat K0831 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Elevate Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Std Sing Pow K0835 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Std Sing Pow K0836 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 2 Hd Sing Pow K0837 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 2 Hd Sing Pow K0838 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Vhd Sing Pow K0839 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Xhd Sing Pow K0840 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Std Mult Pow K0841 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Std Mult Pow K0842 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp2 Hd Mult Pow K0843 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy K0848 Pwc Gp 3 Std Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0849 Pwc Gp 3 Std Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0850 Pwc Gp 3 Hd Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0851 Pwc Gp 3 Hd Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 3 Vhd K0852 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Seat/Back review. MP Criteria: Procedure/service reviewed against Medical Policy K0853 Pwc Gp 3 Vhd Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0854 Pwc Gp 3 Xhd Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0855 Pwc Gp 3 Xhd Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Std Sing Pow K0856 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Std Sing Pow K0857 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Hd Sing Pow K0858 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Hd Sing Pow K0859 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Vhd Sing Pow K0860 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Std Mult Pow K0861 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Hd Mult Pow K0862 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Vhd Mult Pow K0863 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp3 Xhd Mult Pow K0864 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 64/83 MP Criteria: Procedure/service reviewed against Medical Policy K0868 Pwc Gp 4 Std Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0869 Pwc Gp 4 Std Cap Chair Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy K0870 Pwc Gp 4 Hd Seat/Back Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp 4 Vhd K0871 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Seat/Back review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp4 Std Sing Pow K0877 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp4 Std Sing Pow K0878 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp4 Hd Sing Pow K0879 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp4 Vhd Sing Pow K0880 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp4 Std Mult Pow K0884 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp4 Std Mult Pow K0885 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt Cap review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp4 Hd Mult Pow K0886 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp5 Ped Sing Pow K0890 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. MP Criteria: Procedure/service reviewed against Medical Policy Pwc Gp5 Ped Mult Pow K0891 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Opt S/B review. Unlisted: Procedure/service not specifically defined or K0898 Power Wheelchair Noc _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Pow Mobil Dev No K0899 Criteria. Submit for predetermination to avoid post-service DME101.010 Wheelchairs and Accessories _ _ Dmepdac review. EIU: Procedure/service not reimbursed by the Plan. Not subject Ces System W/Supplies K1002 to pre-service review. Check EIU policy CPCP028, which is one SUR702.019 Cranial Electrotherapy Stimulation and Auricular Electrostimulation _ _ Access of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Lo Freq Us Diathermy K1004 to pre-service review. Check EIU policy CPCP028, which is one THE803.008 Non Covered Physical Therapy Services _ _ Device of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bil Hkaf Pc S/D Micro Powered Exoskeleton for Ambulation in Patients With Lower-Limb K1007 to pre-service review. Check EIU policy CPCP028, which is one DME103.008 3/1/2021 _ Sensor Disabilities of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Speech Volume K1009 to pre-service review. Check EIU policy CPCP028, which is one THE803.014 Speech-Language Therapy (SLT) 3/1/2021 _ Modulation Sys of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Speech Volume K1009 Criteria. Submit for predetermination to avoid post-service THE803.014 Speech-Language Therapy (SLT) _ 2/28/2021 Modulation Sys review. Enema Tube Any Non Covered: Procedure/service not covered by the Plan. Not K1013 _ _ 4/1/2021 _ Replac Only subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Ext Up Limb Tremor Non-Reimbursable Experimental, Investigational and/or Unproven K1018 to pre-service review. Check EIU policy CPCP028, which is one CPCP028 8/15/2021 _ Stim Wris Services (EIU) of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Monthly Supp Use With Non-Reimbursable Experimental, Investigational and/or Unproven K1019 to pre-service review. Check EIU policy CPCP028, which is one CPCP028 8/15/2021 _ K1018 Services (EIU) of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Non-invasive vagus K1020 Criteria. Submit for predetermination to avoid post-service SUR712.021 Vagus Nerve Stimulation (VNS) 7/1/2021 _ nerv stim review. Add To Spinal Orthosis Unlisted: Procedure/service not specifically defined or L0999 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or L1499 Spinal Orthosis Nos _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Ko W/0 Joint Rigid L1834 Criteria. Submit for predetermination to avoid post-service DME103.002 Knee Braces _ _ Molded To review. MP Criteria: Procedure/service reviewed against Medical Policy Ko Derot Ant Cruciate L1840 Criteria. Submit for predetermination to avoid post-service DME103.002 Knee Braces _ _ Custom review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 65/83 MP Criteria: Procedure/service reviewed against Medical Policy Ko W/Adj Jt Rot Cntrl L1844 Criteria. Submit for predetermination to avoid post-service DME103.002 Knee Braces _ _ Molded review. MP Criteria: Procedure/service reviewed against Medical Policy Ko W Adj Flex/Ext Rotat L1846 Criteria. Submit for predetermination to avoid post-service DME103.002 Knee Braces _ _ Mold review. Lower Extremity Unlisted: Procedure/service not specifically defined or L2999 _ _ _ _ Orthosis Nos classified, maybe subject to contract/clinical review. Ft Arch Suprt Premold Non Covered: Procedure/service not covered by the Plan. Not L3040 _ _ _ _ Longit subject to pre-service review. Foot Arch Supp Premold Non Covered: Procedure/service not covered by the Plan. Not L3050 _ _ _ _ Metat subject to pre-service review. Foot Arch Supp Non Covered: Procedure/service not covered by the Plan. Not L3060 _ _ _ _ Longitud/Meta subject to pre-service review. Orthopedic Shoe Unlisted: Procedure/service not specifically defined or L3649 _ _ _ _ Modifica Nos classified, maybe subject to contract/clinical review. Upper Limb Orthosis Unlisted: Procedure/service not specifically defined or L3999 _ _ _ _ Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Above Knee Lower-Limb Prosthetics, Including Microprocessor-Controlled L5610 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Hydracadence Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy 4-Bar Link Above Knee Lower-Limb Prosthetics, Including Microprocessor-Controlled L5614 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ W/Swng Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Ak Univ Multiplex Sys Lower-Limb Prosthetics, Including Microprocessor-Controlled L5616 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Frict Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Below Knee Wood Lower-Limb Prosthetics, Including Microprocessor-Controlled L5639 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Socket Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Above Knee Leather Lower-Limb Prosthetics, Including Microprocessor-Controlled L5642 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Socket Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Above Knee Wood Lower-Limb Prosthetics, Including Microprocessor-Controlled L5644 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Socket Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Kne-Shin Exo Sng Axi Lower-Limb Prosthetics, Including Microprocessor-Controlled L5710 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Mnl Loc Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Exo Mnl Lock Lower-Limb Prosthetics, Including Microprocessor-Controlled L5711 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Ultra Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Exo Frict Swg Lower-Limb Prosthetics, Including Microprocessor-Controlled L5712 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ & St Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Exo Variable Lower-Limb Prosthetics, Including Microprocessor-Controlled L5714 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Frict Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Exo Mech Lower-Limb Prosthetics, Including Microprocessor-Controlled L5716 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Stance Ph Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Exo Frct Swg Lower-Limb Prosthetics, Including Microprocessor-Controlled L5718 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ & Sta Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Pneum Swg Lower-Limb Prosthetics, Including Microprocessor-Controlled L5722 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Frct Exo Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Exo Fluid Lower-Limb Prosthetics, Including Microprocessor-Controlled L5724 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Swing Ph Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Ext Jnts Fld Lower-Limb Prosthetics, Including Microprocessor-Controlled L5726 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Swg E Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Fluid Swg & Lower-Limb Prosthetics, Including Microprocessor-Controlled L5728 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Stance Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Lower-Limb Prosthetics, Including Microprocessor-Controlled L5780 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Pneum/Hydra Pneum Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Endo Knee-Shin Polyc Lower-Limb Prosthetics, Including Microprocessor-Controlled L5816 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Mch Sta Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Endo Knee-Shin Frct Lower-Limb Prosthetics, Including Microprocessor-Controlled L5818 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Swg & St Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Lower-Limb Prosthetics, Including Microprocessor-Controlled L5858 Stance Phase Only Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Knee-Shin Pro Flex/Ext Lower-Limb Prosthetics, Including Microprocessor-Controlled L5859 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Cont Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Ak/Ft Power Asst Incl Lower-Limb Prosthetics, Including Microprocessor-Controlled L5969 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Motors Prosthetics review. MP Criteria: Procedure/service reviewed against Medical Policy Ank-Foot Sys Dors-Plant Lower-Limb Prosthetics, Including Microprocessor-Controlled L5973 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Flex Prosthetics review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 66/83 MP Criteria: Procedure/service reviewed against Medical Policy Ft Prosth Multiaxial Lower-Limb Prosthetics, Including Microprocessor-Controlled L5978 Criteria. Submit for predetermination to avoid post-service DME104.012 _ _ Ankl/Ft Prosthetics review. Lowr Extremity Unlisted: Procedure/service not specifically defined or L5999 _ _ _ _ Prosthes Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Part Hand Myo Exclu L6026 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Term Dev review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Additional Switch Ext L6611 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Power review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Flex/Ext Wrist W/Wo L6621 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Friction review. Prosthesis Electric Hand Switch Or Myolelectric Controlled Independently MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Articulating Digits Any L6880 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Grasp Pattern Or review. Prosthesis Combination Of Grasp Patterns Includes Motor(S) MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Microprocessor Control L6882 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Uplmb review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Wrist Disarticul Switch L6920 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Ctrl review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Wrist Disart L6925 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectronic C review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Below Elbow Switch L6930 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Control review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Below Elbow L6935 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectronic Ct review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Elbow Disarticulation L6940 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Switch review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Elbow Disart L6945 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectronic C review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Above Elbow Switch L6950 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Control review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Above Elbow L6955 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectronic Ct review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Shldr Disartic Switch L6960 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Contro review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Shldr Disartic L6965 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectronic review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Interscapular-Thor L6970 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Switch Ct review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Interscap-Thor L6975 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectronic review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic L7007 Adult Electric Hand Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic L7008 Pediatric Electric Hand Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic L7009 Adult Electric Hook Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic L7040 Prehensile Actuator Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic L7045 Pediatric Electric Hook Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Electronic Elbow L7170 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Hosmer Swit review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Electronic Elbow L7180 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Sequential review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Electronic Elbo L7181 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Simultaneous review. Prosthesis

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 67/83 MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Electron Elbow L7185 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Adolescent Sw review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Electron Elbow Child L7186 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Switch review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Elbow Adolescent L7190 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectron review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Elbow Child L7191 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Myoelectronic Ct review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Electronic Wrist Rotator L7259 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Any review. Prosthesis Lower-Limb Prosthetics, Including Microprocessor-Controlled MP Criteria: Procedure/service reviewed against Medical Policy Prosthetics Six Volt Bat Otto DME104.012 L7360 Criteria. Submit for predetermination to avoid post-service Upper-Limb Prosthesis, Including Myoelectric and Orthotic _ _ Bock/Eq Ea DME104.001 review. Components, and Other Prosthetics Except for Lower-Limb Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Twelve Volt Battery L7364 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Utah/Equ review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Battery Chrgr 12 Volt L7366 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Utah/E review. Prosthesis Upper Extremity Unlisted: Procedure/service not specifically defined or L7499 _ _ _ _ Prosthes Nos classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or L8039 Breast Prosthesis Nos _ _ _ _ classified, maybe subject to contract/clinical review. Unspec Maxillofacial Unlisted: Procedure/service not specifically defined or L8048 _ _ _ _ Prosth classified, maybe subject to contract/clinical review. Unlisted Misc Prosthetic Unlisted: Procedure/service not specifically defined or L8499 _ _ _ _ Ser classified, maybe subject to contract/clinical review. Breast Implant, Removal and/or Insertion SUR716.009 Mastopexy MP Criteria: Procedure/service reviewed against Medical Implant Breast SUR716.010 Reconstructive and Contralateral Mammaplasty L8600 Policy Criteria, may require Prior Authorization per contract _ _ Silicone/Eq SUR716.011 Upper-Limb Prosthesis, Including Myoelectric and Orthotic agreement. DME104.001 Components, and Other Prosthetics Except for Lower-Limb Prosthesis Injectable Bulking Agents for the Treatment of Urinary and Fecal MP Criteria: Procedure/service reviewed against Medical Policy Collagen Imp Urinary SUR710.008 Incontinence L8603 Criteria. Submit for predetermination to avoid post-service _ _ 2.5 Ml SUR710.022 Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux review. (VUR) Injectable Bulking Agents for the Treatment of Urinary and Fecal MP Criteria: Procedure/service reviewed against Medical Policy Dextranomer/Hyaluroni SUR710.008 Incontinence L8604 Criteria. Submit for predetermination to avoid post-service _ _ c Acid SUR710.022 Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux review. (VUR) EIU: Procedure/service not reimbursed by the Plan. Not subject Inj Bulking Agent Anal Injectable Bulking Agents for the Treatment of Urinary and Fecal L8605 to pre-service review. Check EIU policy CPCP028, which is one SUR710.008 _ _ Canal Incontinence of our Clinical Payment and Coding Policy (CPCP). Injectable Bulking Agents for the Treatment of Urinary and Fecal MP Criteria: Procedure/service reviewed against Medical Policy Synthetic Implnt SUR710.008 Incontinence L8606 Criteria. Submit for predetermination to avoid post-service _ _ Urinary 1Ml SUR710.022 Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux review. (VUR) EIU: Procedure/service not reimbursed by the Plan. Not subject Arg Ii Ext Com/Sup/Acc L8608 to pre-service review. Check EIU policy CPCP028, which is one SUR713.026 Retinal Prosthesis _ _ Misc of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Aqueous Shunt L8612 Criteria. Submit for predetermination to avoid post-service SUR713.034 Aqueous Shunts and Stents for Glaucoma _ _ Prosthesis review. MP Criteria: Procedure/service reviewed against Medical L8614 Cochlear Device Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Coch Implant Headset L8615 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Replace agreement. MP Criteria: Procedure/service reviewed against Medical Coch Implant L8616 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Microphone Repl agreement. MP Criteria: Procedure/service reviewed against Medical Coch Implant Trans Coil L8617 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Repl agreement. MP Criteria: Procedure/service reviewed against Medical Coch Implant Tran L8618 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Cable Repl agreement. MP Criteria: Procedure/service reviewed against Medical Coch Imp Ext L8619 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Proc/Contr Rplc agreement. MP Criteria: Procedure/service reviewed against Medical L8621 Repl Zinc Air Battery Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ agreement. MP Criteria: Procedure/service reviewed against Medical L8622 Repl Alkaline Battery Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 68/83 MP Criteria: Procedure/service reviewed against Medical Lith Ion Batt Cid Non- L8623 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Earlvl agreement. MP Criteria: Procedure/service reviewed against Medical Lith Ion Batt Cid Ear L8624 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Level agreement. MP Criteria: Procedure/service reviewed against Medical Cid Ext Speech Process L8627 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Repl agreement. MP Criteria: Procedure/service reviewed against Medical L8628 Cid Ext Controller Repl Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Cid Transmit Coil And L8629 Policy Criteria, may require Prior Authorization per contract SUR714.004 Cochlear Implant _ _ Cable agreement. MP Criteria: Procedure/service reviewed against Medical Aud Osseo Dev Int/Ext L8690 Policy Criteria, may require Prior Authorization per contract SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ Comp agreement. MP Criteria: Procedure/service reviewed against Medical Aoi Snd Proc Repl Excl L8691 Policy Criteria, may require Prior Authorization per contract SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ Actua agreement. MP Criteria: Procedure/service reviewed against Medical Aud Osseo Dev L8693 Policy Criteria, may require Prior Authorization per contract SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ Abutment agreement. Aoi MP Criteria: Procedure/service reviewed against Medical Policy L8694 Transducer/Actuator Criteria. Submit for predetermination to avoid post-service SUR714.003 Implantable Bone-Conduction and Bone-Anchored Hearing Aids _ _ Repl review. MP Criteria: Procedure/service reviewed against Medical Policy Misc Used With Tot Art L8698 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Heart review. Unlisted: Procedure/service not specifically defined or L8699 Prosthetic Implant Nos _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Ewh S/D Uprt Micro L8701 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Sensor review. Prosthesis MP Criteria: Procedure/service reviewed against Medical Policy Upper-Limb Prosthesis, Including Myoelectric and Orthotic Ewhf S/D Uprt Micro L8702 Criteria. Submit for predetermination to avoid post-service DME104.001 Components, and Other Prosthetics Except for Lower-Limb _ _ Sensor review. Prosthesis Non Covered: Procedure/service not covered by the Plan. Not M0075 Cellular Therapy _ _ _ _ subject to pre-service review. Intragastric Non Covered: Procedure/service not covered by the Plan. Not M0100 _ _ _ _ Hypothermia subject to pre-service review. bamlanivimab-xxxx Non Covered: Procedure/service not covered by the Plan. Not M0239 _ _ 4/16/2021 infusion subject to pre-service review. Fabric Wrapping Of Non Covered: Procedure/service not covered by the Plan. Not M0301 _ _ _ _ Aneurysm subject to pre-service review. Cephalin Floculation Non Covered: Procedure/service not covered by the Plan. Not P2028 _ _ _ _ Test subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not P2029 Congo Red Blood Test _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy P2031 Hair Analysis Criteria. Submit for predetermination to avoid post-service PSY301.014 Autism Spectrum Disorders (ASD) _ _ review. Non Covered: Procedure/service not covered by the Plan. Not P2033 Blood Thymol Turbidity _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not P2038 Blood Mucoprotein _ _ _ _ subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Orthopedic Applications of Platelet-Rich Plasma RX501.101 P9020 Plaelet Rich Plasma Unit to pre-service review. Check EIU policy CPCP028, which is one Recombinant and Autologous Platelet-Derived Growth Factors for _ _ RX501.034 of our Clinical Payment and Coding Policy (CPCP). Wound Healing and Other Non-Orthopedic Conditions Blood Unlisted: Procedure/service not specifically defined or P9099 Component/Product _ _ _ _ classified, maybe subject to contract/clinical review. Noc Non Covered: Procedure/service not covered by the Plan. Not Q0239 Bamlanivimab-Xxxx _ _ _ _ subject to pre-service review. Casirivimab And Non Covered: Procedure/service not covered by the Plan. Not Q0243 _ _ _ _ Imdevimab subject to pre-service review. Casirivi and imdevi 1200 Non Covered: Procedure/service not covered by the Plan. Not Q0244 _ _ 6/3/2021 _ mg subject to pre-service review. Bamlanivimab And Non Covered: Procedure/service not covered by the Plan. Not Q0245 _ _ 2/9/2021 _ Etesevima subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Pwr Module Pt Cable Q0477 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Lvad Rpl review. MP Criteria: Procedure/service reviewed against Medical Policy Microprcsr Cu Combo Q0482 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Vad Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Monitor Elec Or Comb Q0484 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Vad Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Monitor Cable Elec Vad Q0485 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Leads Any Type Vad Q0487 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Rep Only review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 69/83 MP Criteria: Procedure/service reviewed against Medical Policy Pwr Pack Base Elec Vad Q0488 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Pwr Pck Base Combo Q0489 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Vad Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Emr Pwr Source Elec Q0490 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Vad Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Emr Pwr Source Combo Q0491 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Vad Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Emr Pwr Cbl Elec Vad Q0492 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Emr Pwr Cbl Combo Vad Q0493 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Emr Hd Pmp Q0494 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Elec/Combo Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Filters Elec/Combo Vad Q0500 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Rep review. MP Criteria: Procedure/service reviewed against Medical Policy Pwr Adpt Pneum Vad Q0504 Criteria. Submit for predetermination to avoid post-service SUR707.017 Ventricular Assist Devices and Total Artificial Hearts _ _ Rep Veh review. Unlisted: Procedure/service not specifically defined or Q0507 Misc Sup/Acc Ext Vad _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or Q0508 Misc Sup/Acc Imp Vad _ _ _ _ classified, maybe subject to contract/clinical review. Mis Sup/Ac Imp Vad Unlisted: Procedure/service not specifically defined or Q0509 _ _ _ _ Nopay Med classified, maybe subject to contract/clinical review. Dispens Fee Non Covered: Procedure/service not covered by the Plan. Not Q0510 _ _ _ _ Immunosupressive subject to pre-service review. Sup Fee Antiem Antica Non Covered: Procedure/service not covered by the Plan. Not Q0511 _ _ _ _ Immuno subject to pre-service review. Px Sup Fee Anti-Can Sub Non Covered: Procedure/service not covered by the Plan. Not Q0512 _ _ _ _ Pres subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Q2026 Radiesse Injection Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Q2028 Inj Sculptra 0.5Mg Criteria. Submit for predetermination to avoid post-service SUR716.001 Cosmetic and Reconstructive Procedures _ _ review. Influenza Virus Vaccine Unlisted: Procedure/service not specifically defined or Q2039 _ _ _ _ Nos classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Axicabtagene Ciloleucel Q2041 Policy Criteria, may require Prior Authorization per contract RX501.088 Chimeric Antigen Receptor (CAR) T-cell Therapy _ _ Car+ agreement. MP Criteria: Procedure/service reviewed against Medical Tisagenlecleucel Car- Q2042 Policy Criteria, may require Prior Authorization per contract RX501.088 Chimeric Antigen Receptor (CAR) T-cell Therapy _ _ Pos T agreement. Sipuleucel-T Minimum Of 50 Million Autologous Cd54+ Cells Activated With Pap-Gm- MP Criteria: Procedure/service reviewed against Medical Cellular Immunotherapy for Prostate Cancer (Sipuleucel-T Q2043 Csf Including Policy Criteria, may require Prior Authorization per contract RX501.074 _ _ [Provenge]) Leukapheresis And All agreement. Other Preparatory Procedures Per Infusion Unlisted: Procedure/service not specifically defined or Q2050 Doxorubicin Inj 10Mg _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Brexucabtagene car pos Q2053 Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications 4/1/2021 _ t review. Unlisted: Procedure/service not specifically defined or Q4050 Cast Supplies Unlisted _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or Q4051 Splint Supplies Misc _ _ _ _ classified, maybe subject to contract/clinical review. Drug/Bio Noc Part B Non Covered: Procedure/service not covered by the Plan. Not Q4082 _ _ _ _ Drug Cap subject to pre-service review. Unlisted: Procedure/service not specifically defined or Q4100 Skin Substitute Nos _ _ _ _ classified, maybe subject to contract/clinical review. EIU: Procedure/service not reimbursed by the Plan. Not subject Q4103 Oasis Burn Matrix to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4104 Integra Bmwd to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 70/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Q4110 Primatrix to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4111 Gammagraft to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4112 Cymetra Injectable to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4113 Graftjacket Xpress to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4115 Alloskin to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4117 Hyalomatrix to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4118 Matristem Micromatrix to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4121 Theraskin to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4122 Dermacell, Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 4/1/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Alloskin Rt Per Square Q4123 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Centimeter of our Clinical Payment and Coding Policy (CPCP).

Oasis Ultra Tri-Layer EIU: Procedure/service not reimbursed by the Plan. Not subject Q4124 Wound Matrix Per to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Square Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Arthroflex Per Square Q4125 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Memoderm/Derma/Tra Q4126 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ nz/Integup of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Talymed Per Square Q4127 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Strattice Tm Per Square Q4130 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Centimeter of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Grafix core grafixpl Q4132 Criteria. Submit for predetermination to avoid post-service SUR704.011 Amniotic Membrane and Amniotic Fluid 08/15/2021 _ core review. MP Criteria: Procedure/service reviewed against Medical Policy Grafix stravix prime pl Q4133 Criteria. Submit for predetermination to avoid post-service SUR704.011 Amniotic Membrane and Amniotic Fluid 08/15/2021 _ sqcm review. EIU: Procedure/service not reimbursed by the Plan. Not subject Q4134 Hmatrix to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4135 Mediskin to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4136 Ezderm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amnioexcel Biodexcel Q4137 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ 1Sq Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4138 Biodfence Dryflex 1Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 71/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Amnio Or Biodmatrix Q4139 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Inj 1Cc of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4140 Biodfence 1Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4141 Alloskin Ac 1 Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Xcm Biologic Tiss Matrix Q4142 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ 1Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4143 Repriza 1Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4145 Epifix Inj 1Mg to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4146 Tensix 1Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Architect Ecm Px Fx 1 Sq Q4147 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Neox Neox Rt Or Clarix Q4148 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cord of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4149 Excellagen 0.1 Cc to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Allowrap Ds Or Dry 1 Sq Q4150 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Amnioband guardian 1 Q4151 Criteria. Submit for predetermination to avoid post-service SUR704.011 Amniotic Membrane and Amniotic Fluid 08/15/2021 _ sq cm review. EIU: Procedure/service not reimbursed by the Plan. Not subject Dermapure 1 Square Q4152 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Dermavest Plurivest Sq Q4153 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Q4154 Biovance 1 square cm Criteria. Submit for predetermination to avoid post-service SUR704.011 Amniotic Membrane and Amniotic Fluid 08/15/2021 _ review. EIU: Procedure/service not reimbursed by the Plan. Not subject Neoxflo Or Clarixflo 1 Q4155 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Mg of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4156 Neox 100 Or Clarix 99 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4157 Revitalon 1 Square Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Kerecis Omega3 Per Sq Q4158 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4159 Affinity1 Square Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4160 Nushield 1 Square Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bio-Connekt Per Square Q4161 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Cm of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 72/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Wndex Flw Bioskn Flw Q4162 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ 0.5Cc of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Woundex Bioskin Per Q4163 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Sq Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4164 Helicoll Per Square Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Keramatrix Kerasorb Sq Q4165 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cytal Per Square Q4166 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Truskin Per Sq Q4167 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Centimeter of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Q4168 Amnioband 1 mg Criteria. Submit for predetermination to avoid post-service SUR704.011 Amniotic Membrane and Amniotic Fluid 08/15/2021 _ review. EIU: Procedure/service not reimbursed by the Plan. Not subject Artacent Wound Per Sq Q4169 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4170 Cygnus Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4171 Interfyl 1 Mg to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Palingen Or Palingen Q4173 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Xplus of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4174 Palingen Or Promatrx to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4175 Miroderm, Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 4/1/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Neopatch Or Therion Q4176 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Per Square Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4177 Floweramnioflo 0.1 Cc to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Floweramniopatch Per Q4178 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Sq Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4179 Flowerderm Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4180 Revita Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amnio Wound Per Q4181 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Square Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Transcyte Per Sq Q4182 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4183 Surgigraft 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cellesta Or Duo Per Sq Q4184 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 73/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Cellesta Flowab Amnion Q4185 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ 0.5Cc of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Q4186 Epifix 1 sq cm Criteria. Submit for predetermination to avoid post-service SUR704.011 Amniotic Membrane and Amniotic Fluid 08/15/2021 _ review. EIU: Procedure/service not reimbursed by the Plan. Not subject Q4188 Amnioarmor 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4189 Artacent Ac 1 Mg to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4190 Artacent Ac 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4191 Restorigin 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4192 Restorigin 1 Cc to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4193 Coll-E-Derm 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4194 Novachor 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Q4195 Puraply 1 Sq Cm Criteria. Submit for predetermination to avoid post-service SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ 5/14/2021 review. EIU: Procedure/service not reimbursed by the Plan. Not subject Q4195 Puraply 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Q4196 Puraply Am 1 Sq Cm Criteria. Submit for predetermination to avoid post-service SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ 5/14/2021 review. EIU: Procedure/service not reimbursed by the Plan. Not subject Q4196 Puraply Am 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4197 Puraply Xt 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Genesis Amnio Q4198 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Membrane 1Sqcm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4200 Skin Te 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4201 Matrion 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4202 Keroxx (2.5G/Cc) 1Cc to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4203 Derma-Gide 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4204 Xwrap 1 Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Membrane Graft Or Q4205 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Wrap Sq Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Fluid Flow Or Fluid Gf 1 Q4206 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cc of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 74/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Q4208 Novafix Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4209 Surgraft Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Axolotl Graf Dualgraf Sq Q4210 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amnion Bio Or Axobio Q4211 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Sq Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4212 Allogen Per Cc to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4213 Ascent 0.5 Mg to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4214 Cellesta Cord Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Axolotl Ambient Cryo Q4215 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ 0.1 Mg of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Artacent Cord Per Sq Q4216 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Woundfix Biowound Q4217 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Plus Xplus of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4218 Surgicord Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Surgigraft Dual Per Sq Q4219 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bellacell Hd Surederm Q4220 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Sq Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4221 Amniowrap2 Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Progenamatrix Per Sq Q4222 to pre-service review. Check EIU policy CPCP028, which is one SUR704.012 Bioengineered Skin and Soft Tissue Substitutes 5/15/2021 _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4227 Amniocore Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Bionextpatch Per Sq Q4228 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cogenex Amnio Memb Q4229 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Per Sq Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cogenex Flow Amnion Q4230 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ 0.5 Cc of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4231 Corplex P Per Cc to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4232 Corplex Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 75/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Surfactor /Nudyn Per Q4233 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ 0.5 Cc of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4234 Xcellerate Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amniorepair Or Altiply, Q4235 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Per Square of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Carepatch, Per Square Q4236 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Cryo-Cord, Per Square Q4237 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Centimeter of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amnio-Maxx Or Amnio- Q4239 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Maxx Lite, Per of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Corecyte, For Topical Q4240 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Use Only, Per of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Polycyte, For Topical Q4241 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Use Only, Per of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amniocyte Plus, Per 0.5 Q4242 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cc of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4244 Procenta, Per 200 Mg to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4245 Amniotext, Per Cc to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Coretext Or Protext, Per Q4246 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Cc of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amniotext Patch, Per Q4247 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Square Centime of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Dermacyte Amniotic Q4248 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid _ _ Membrane Allogra of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4249 Amniply Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid 3/1/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Amnioamp-Mp Per Sq Q4250 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid 3/1/2021 _ Cm of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Q4254 Novafix Dl Per Sq Cm to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid 3/1/2021 _ of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Reguard Topical Use Q4255 to pre-service review. Check EIU policy CPCP028, which is one SUR704.011 Amniotic Membrane and Amniotic Fluid 3/1/2021 _ Per Sq of our Clinical Payment and Coding Policy (CPCP). Unlisted: Procedure/service not specifically defined or Q5009 Hospice Care Nos _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical RX501.051 Infliximab and Associated Biosimilars Q5103 Injection Inflectra Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical RX501.051 Infliximab and Associated Biosimilars Q5104 Injection Renflexis Policy Criteria, may require Prior Authorization per contract _ _ RX501.096 Specialty Medication Administration Site of Care agreement. MP Criteria: Procedure/service reviewed against Medical Policy Inj Retacrit Non-Esrd Q5106 Criteria. Submit for predetermination to avoid post-service RX501.069 Erythropoiesis-Stimulating Agents (ESAs) _ _ Use review. MP Criteria: Procedure/service reviewed against Medical Policy Q5107 Inj Mvasi 10 Mg Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 76/83 MP Criteria: Procedure/service reviewed against Medical Q5109 Injection Ixifi 10 Mg Policy Criteria, may require Prior Authorization per contract RX501.051 Infliximab and Associated Biosimilars _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Policy Q5115 Inj Truxima 10 Mg Criteria. Submit for predetermination to avoid post-service RX502.030 Rituximab and Biosimilars for Non-Oncologic Indications _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Q5118 Inj. Zirabev 10 Mg Criteria. Submit for predetermination to avoid post-service RX502.061 Oncology Medications _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Q5119 Inj Ruxience 10 Mg Criteria. Submit for predetermination to avoid post-service RX502.030 Rituximab and Biosimilars for Non-Oncologic Indications _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Q5123 Inj. riabni 10 mg Criteria. Submit for predetermination to avoid post-service RX502.030 Rituximab and Biosimilars for Non-Oncologic Indications 7/1/2021 _ review. MP Criteria: Procedure/service reviewed against Medical Policy Esketamine Nasal S0013 Criteria. Submit for predetermination to avoid post-service RX501.105 Esketamine Nasal Spray 2/1/2021 _ Spray review. Non Covered: Procedure/service not covered by the Plan. Not S0117 Tretinoin Topical 5 G _ _ _ _ subject to pre-service review. Colistimethate Inh Sol Non Covered: Procedure/service not covered by the Plan. Not S0142 _ _ _ _ Mg subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Advanced Therapies for Pharmacologic Treatment of Pulmonary S0155 Epoprostenol Dilutant Criteria. Submit for predetermination to avoid post-service RX501.056 _ _ Hypertension review. MP Criteria: Procedure/service reviewed against Medical Becaplermin Gel 1% 0.5 Recombinant and Autologous Platelet-Derived Growth Factors for S0157 Policy Criteria, may require Prior Authorization per contract RX501.034 _ _ Gm Wound Healing and Other Non-Orthopedic Conditions agreement. Gender Assignment Surgery and Gender Reassignment Surgery MP Criteria: Procedure/service reviewed against Medical SUR717.001 with Related Services Testosterone Pellet 75 S0189 Policy Criteria, may require Prior Authorization per contract RX501.007 Hormone Replacement Therapies (HRT) Using Implanted Pellets for _ _ Mg agreement. RX501.076 Women and Delayed Puberty Testosterone Replacement Therapies Prenatal Vitamins 30 Non Covered: Procedure/service not covered by the Plan. Not S0197 _ _ _ _ Day subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S0209 Wc Van Mileage Per Mi _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Nonemerg Transp S0215 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ Mileage review. Non Covered: Procedure/service not covered by the Plan. Not S0310 Hospitalist Visit _ _ _ _ subject to pre-service review. Rn Telephone Calls To Non Covered: Procedure/service not covered by the Plan. Not S0320 _ _ _ _ Dmp subject to pre-service review. Unlisted: Procedure/service not specifically defined or S0590 Misc Integral Lens Serv _ _ _ _ classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not S0622 Phys Exam For College _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Laser In Situ S0800 Criteria. Submit for predetermination to avoid post-service SUR713.001 Refractive and Therapeutic Keratoplasty _ _ Keratomileusis review. MP Criteria: Procedure/service reviewed against Medical Policy Photorefractive S0810 Criteria. Submit for predetermination to avoid post-service SUR713.001 Refractive and Therapeutic Keratoplasty _ _ Keratectomy review. Unlisted: Procedure/service not specifically defined or S1001 Deluxe Item _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or S1002 Custom Item _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Glucose Monitoring and Insulin Delivery Devices for Managing S1030 Gluc Monitor Purchase Criteria. Submit for predetermination to avoid post-service DME101.005 _ _ Diabetes review. MP Criteria: Procedure/service reviewed against Medical Policy Glucose Monitoring and Insulin Delivery Devices for Managing S1031 Gluc Monitor Rental Criteria. Submit for predetermination to avoid post-service DME101.005 _ _ Diabetes review. MP Criteria: Procedure/service reviewed against Medical Policy Cranial Remolding Adjustable Cranial Orthoses for Positional Plagiocephaly and S1040 Criteria. Submit for predetermination to avoid post-service DME103.007 _ _ Orthosis Craniosynostoses review. MP Criteria: Procedure/service reviewed against Medical Policy S2068 Breast Diep Or Siea Flap Criteria. Submit for predetermination to avoid post-service SUR716.011 Reconstructive and Contralateral Mammaplasty _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Adjustment Gastric S2083 Criteria. Submit for predetermination to avoid post-service SUR716.003 Bariatric Surgery _ _ Band review. MP Criteria: Procedure/service reviewed against Medical Policy Adrenal Tissue S2103 Criteria. Submit for predetermination to avoid post-service SUR703.003 Brain Tissue Transplantation and Neurotransplantation _ _ Transplant review. EIU: Procedure/service not reimbursed by the Plan. Not subject S2117 Arthroereisis Subtalar to pre-service review. Check EIU policy CPCP028, which is one SUR705.027 Subtalar Arthroereisis (STA) _ _ of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical S2118 Total Hip Resurfacing Policy Criteria, may require Prior Authorization per contract SUR705.019 Hip Resurfacing (HR) _ _ agreement. MP Criteria: Procedure/service reviewed against Medical Low Density S2120 Policy Criteria, may require Prior Authorization per contract THE802.003 Lipid Apheresis _ _ Lipoprotein(Ldl) agreement.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 77/83 Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion Following Preparative Regimens (General Donor and Recipient SUR703.037 Information) SUR703.002 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.043 Lymphoblastic Leukemia (ALL) SUR703.047 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.036 Syndrome (AIDS) SUR703.038 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.039 Hematopoietic Cell Transplantation for Breast Cancer SUR703.029 Hematopoietic Cell Transplantation for Central Nervous System SUR703.041 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Policy SUR703.034 Hematopoietic Cell Transplantation for Chronic Lymphocytic S2140 Cord Blood Harvesting Criteria. Submit for predetermination to avoid post-service SUR703.033 _ _ Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) review. SUR703.040 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.042 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.035 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.032 Acquired Anemias SUR703.031 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.030 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.046 and Gliomas SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion Following Preparative Regimens (General Donor and Recipient SUR703.037 Information) SUR703.002 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.043 Lymphoblastic Leukemia (ALL) SUR703.047 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.036 Syndrome (AIDS) SUR703.038 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.039 Hematopoietic Cell Transplantation for Breast Cancer SUR703.029 Hematopoietic Cell Transplantation for Central Nervous System SUR703.041 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Policy SUR703.034 Cord Blood-Derived Hematopoietic Cell Transplantation for Chronic Lymphocytic S2142 Criteria. Submit for predetermination to avoid post-service SUR703.033 _ _ Stem-Cell Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) review. SUR703.040 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.042 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.035 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.032 Acquired Anemias SUR703.031 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.030 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.046 and Gliomas SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Hematopoietic Cell Transplantation for Acute Myelogenous Leukemia (AML) Hematopoietic Cell Transplantation (HCT) or Additional Infusion Following Preparative Regimens (General Donor and Recipient SUR703.037 Information) SUR703.002 Hematopoietic Cell Transplantation as a Treatment of Acute SUR703.043 Lymphoblastic Leukemia (ALL) SUR703.047 Hematopoietic Cell Transplantation for Acquired Immunodeficiency SUR703.036 Syndrome (AIDS) SUR703.038 Hematopoietic Cell Transplantation for Autoimmune Diseases SUR703.039 Hematopoietic Cell Transplantation for Breast Cancer SUR703.029 Hematopoietic Cell Transplantation for Central Nervous System SUR703.041 Embryonal Tumors and Ependymoma MP Criteria: Procedure/service reviewed against Medical Policy SUR703.034 Bmt Harv/Transpl 28D Hematopoietic Cell Transplantation for Chronic Lymphocytic S2150 Criteria. Submit for predetermination to avoid post-service SUR703.033 _ _ Pkg Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) review. SUR703.040 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia SUR703.042 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer SUR703.035 Hematopoietic Cell Transplantation for Genetic Diseases and SUR703.032 Acquired Anemias SUR703.031 Hematopoietic Cell Transplantation for Hodgkin Lymphoma (HL) SUR703.030 Hematopoietic Cell Transplantation for Malignant Astrocytomas SUR703.046 and Gliomas SUR703.044 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors SUR703.050 in Adults SUR703.045 Hematopoietic Cell Transplantation for Myelodysplastic Syndromes (MDS) and Myeloproliferative Neoplasms (MPN) Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, MP Criteria: Procedure/service reviewed against Medical Policy S2202 Echosclerotherapy Criteria. Submit for predetermination to avoid post-service SUR707.016 Varicose Vein Management _ _ review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 78/83 MP Criteria: Procedure/service reviewed against Medical Policy Minimally Invasive S2205 Criteria. Submit for predetermination to avoid post-service SUR707.020 Minimally Invasive Coronary Artery Bypass Graft Surgery _ _ Direct Co review. MP Criteria: Procedure/service reviewed against Medical Policy Minimally Invasive S2206 Criteria. Submit for predetermination to avoid post-service SUR707.020 Minimally Invasive Coronary Artery Bypass Graft Surgery _ _ Direct Co review. MP Criteria: Procedure/service reviewed against Medical Policy Minimally Invasive S2207 Criteria. Submit for predetermination to avoid post-service SUR707.020 Minimally Invasive Coronary Artery Bypass Graft Surgery _ _ Direct Co review. MP Criteria: Procedure/service reviewed against Medical Policy Minimally Invasive S2208 Criteria. Submit for predetermination to avoid post-service SUR707.020 Minimally Invasive Coronary Artery Bypass Graft Surgery _ _ Direct Co review. MP Criteria: Procedure/service reviewed against Medical Policy Minimally Invasive S2209 Criteria. Submit for predetermination to avoid post-service SUR707.020 Minimally Invasive Coronary Artery Bypass Graft Surgery _ _ Direct Co review. MP Criteria: Procedure/service reviewed against Medical Policy S2230 Implant Semi-Imp Hear Criteria. Submit for predetermination to avoid post-service SUR714.008 Semi-Implantable and Fully Implantable Middle Ear Hearing Aids _ _ review. MP Criteria: Procedure/service reviewed against Medical Policy Implant Auditory Brain S2235 Criteria. Submit for predetermination to avoid post-service SUR714.009 Auditory Brainstem Implant _ _ Imp review. EIU: Procedure/service not reimbursed by the Plan. Not subject Arthroscopy Shoulder S2300 to pre-service review. Check EIU policy CPCP028, which is one SUR705.041 Thermal Capsulorrhaphy as a Treatment of Joint Instability _ _ Surgi of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Fetal Surg Congen S2400 Criteria. Submit for predetermination to avoid post-service SUR701.016 Fetal Surgery for Prenatally Diagnosed Malformations _ _ Hernia review. MP Criteria: Procedure/service reviewed against Medical Policy Fetal Surg Pulmon S2403 Criteria. Submit for predetermination to avoid post-service SUR701.016 Fetal Surgery for Prenatally Diagnosed Malformations _ _ Sequest review. MP Criteria: Procedure/service reviewed against Medical Policy Fetal Surg Sacrococ S2405 Criteria. Submit for predetermination to avoid post-service SUR701.016 Fetal Surgery for Prenatally Diagnosed Malformations _ _ Teratoma review. Unlisted: Procedure/service not specifically defined or S2409 Fetal Surg Noc _ _ _ _ classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not S3600 Stat Lab _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S3601 Stat Lab Home/Nf _ _ _ _ subject to pre-service review. EIU: Procedure/service not reimbursed by the Plan. Not subject Saliva Test Hormone S3650 to pre-service review. Check EIU policy CPCP028, which is one MED207.128 Salivary Hormone Testing _ _ Level; of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Saliva Test Hormone S3652 to pre-service review. Check EIU policy CPCP028, which is one MED207.128 Salivary Hormone Testing _ _ Level; of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Surface Scanning Electromyography (EMG) (SEMG), Paraspinal S3900 Surface Emg to pre-service review. Check EIU policy CPCP028, which is one MED205.006 _ _ Surface EMG, and Spinoscopy of our Clinical Payment and Coding Policy (CPCP). Complete Ivf Nos Case Unlisted: Procedure/service not specifically defined or S4015 _ _ _ _ Rate classified, maybe subject to contract/clinical review. Incompl Donor Egg Case Non Covered: Procedure/service not covered by the Plan. Not S4023 _ _ _ _ Rate subject to pre-service review. Donor Serv Ivf Case Non Covered: Procedure/service not covered by the Plan. Not S4025 _ _ _ _ Rate subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S4026 Procure Donor Sperm _ _ _ _ subject to pre-service review. Store Prev Froz Non Covered: Procedure/service not covered by the Plan. Not S4027 _ _ _ _ Embryos subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S4030 Sperm Procure Init Visit _ _ _ _ subject to pre-service review. Sperm Procure Subs Non Covered: Procedure/service not covered by the Plan. Not S4031 _ _ _ _ Visit subject to pre-service review. Monit Store Cryo Non Covered: Procedure/service not covered by the Plan. Not S4040 _ _ _ _ Embryo 30 D subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S4990 Nicotine Patch Legend _ _ _ _ subject to pre-service review. Nicotine Patch Non Covered: Procedure/service not covered by the Plan. Not S4991 _ _ _ _ Nonlegend subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S4995 Smoking Cessation Gum _ _ _ _ subject to pre-service review. Hit Routine Device Non Covered: Procedure/service not covered by the Plan. Not S5035 _ _ _ _ Maint subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S5036 Hit Device Repair _ _ _ _ subject to pre-service review. Adult Daycare Services Non Covered: Procedure/service not covered by the Plan. Not S5100 _ _ _ _ 15Min subject to pre-service review. Adult Day Care Per Half Non Covered: Procedure/service not covered by the Plan. Not S5101 _ _ _ _ Day subject to pre-service review. Adult Day Care Per Non Covered: Procedure/service not covered by the Plan. Not S5102 _ _ _ _ Diem subject to pre-service review. Centerbased Day Care Non Covered: Procedure/service not covered by the Plan. Not S5105 _ _ _ _ Perdiem subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 79/83 Homecare Train Pt 15 Non Covered: Procedure/service not covered by the Plan. Not S5108 _ _ _ _ Min subject to pre-service review. Homecare Train Pt Non Covered: Procedure/service not covered by the Plan. Not S5109 _ _ _ _ Session subject to pre-service review. Family Homecare Non Covered: Procedure/service not covered by the Plan. Not S5110 _ _ _ _ Training 15M subject to pre-service review. Family Homecare Non Covered: Procedure/service not covered by the Plan. Not S5111 _ _ _ _ Train/Sessio subject to pre-service review. Nonfamily Homecare Non Covered: Procedure/service not covered by the Plan. Not S5115 _ _ _ _ Train/15M subject to pre-service review. Nonfamily Hc Non Covered: Procedure/service not covered by the Plan. Not S5116 _ _ _ _ Train/Session subject to pre-service review. Chore Services Per 15 Non Covered: Procedure/service not covered by the Plan. Not S5120 _ _ _ _ Min subject to pre-service review. Chore Services Per Non Covered: Procedure/service not covered by the Plan. Not S5121 _ _ _ _ Diem subject to pre-service review. Attendant Care Service Non Covered: Procedure/service not covered by the Plan. Not S5125 _ _ _ _ /15M subject to pre-service review. Attendant Care Service Non Covered: Procedure/service not covered by the Plan. Not S5126 _ _ _ _ /Diem subject to pre-service review. Homaker Service Nos Non Covered: Procedure/service not covered by the Plan. Not S5130 _ _ _ _ Per 15M subject to pre-service review. Homemaker Service Non Covered: Procedure/service not covered by the Plan. Not S5131 _ _ _ _ Nos /Diem subject to pre-service review. Adult Companioncare Non Covered: Procedure/service not covered by the Plan. Not S5135 _ _ _ _ Per 15M subject to pre-service review.

Adult Companioncare Non Covered: Procedure/service not covered by the Plan. Not S5136 _ _ _ _ Per Diem subject to pre-service review. Adult Foster Care Per Non Covered: Procedure/service not covered by the Plan. Not S5140 _ _ _ _ Diem subject to pre-service review. Adult Foster Care Per Non Covered: Procedure/service not covered by the Plan. Not S5141 _ _ _ _ Month subject to pre-service review. Child Fostercare Th Per Non Covered: Procedure/service not covered by the Plan. Not S5145 _ _ _ _ Diem subject to pre-service review. Ther Fostercare Child Non Covered: Procedure/service not covered by the Plan. Not S5146 _ _ _ _ /Month subject to pre-service review. Unskilled Respite Care Non Covered: Procedure/service not covered by the Plan. Not S5150 _ _ _ _ /15M subject to pre-service review. Unskilled Respitecare Non Covered: Procedure/service not covered by the Plan. Not S5151 _ _ _ _ /Diem subject to pre-service review. Emer Response Sys Non Covered: Procedure/service not covered by the Plan. Not S5160 _ _ _ _ Instal&Tst subject to pre-service review. Emer Rspns Sys Serv Non Covered: Procedure/service not covered by the Plan. Not S5161 _ _ _ _ Permonth subject to pre-service review. Emer Rspns System Non Covered: Procedure/service not covered by the Plan. Not S5162 _ _ _ _ Purchase subject to pre-service review. Home Modifications Per Non Covered: Procedure/service not covered by the Plan. Not S5165 _ _ _ _ Serv subject to pre-service review. Homedelivered Non Covered: Procedure/service not covered by the Plan. Not S5170 _ _ _ _ Prepared Meal subject to pre-service review. Laundry Serv Ext Prof Non Covered: Procedure/service not covered by the Plan. Not S5175 _ _ _ _ /Order subject to pre-service review. Hh Respiratory Thrpy Unlisted: Procedure/service not specifically defined or S5181 _ _ _ _ Nos/Day classified, maybe subject to contract/clinical review. Med Reminder Serv Per Non Covered: Procedure/service not covered by the Plan. Not S5185 _ _ _ _ Month subject to pre-service review. Personal Care Item Nos Non Covered: Procedure/service not covered by the Plan. Not S5199 _ _ _ _ Each subject to pre-service review. Unlisted: Procedure/service not specifically defined or S5497 Hit Cath Care Noc _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Autism Spectrum Disorders (ASD) Magnetic Source PSY301.014 S8035 Criteria. Submit for predetermination to avoid post-service Magnetoencephalography (MEG) and Magnetic Source Imaging _ _ Imaging RAD601.038 review. (MSI) EIU: Procedure/service not reimbursed by the Plan. Not subject Interferential Current S8130 to pre-service review. Check EIU policy CPCP028, which is one MED201.041 Interferential Current Stimulation _ _ Stimulator 2 Channel of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Interferential Current S8131 to pre-service review. Check EIU policy CPCP028, which is one MED201.041 Interferential Current Stimulation _ _ Stimulator 4 Channel of our Clinical Payment and Coding Policy (CPCP). Unlisted: Procedure/service not specifically defined or S8189 Trach Supply Noc _ _ _ _ classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not S8270 Enuresis Alarm _ _ _ _ subject to pre-service review. Infect Control Supplies Unlisted: Procedure/service not specifically defined or S8301 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not S8460 Camisole Post-Mast _ _ _ _ subject to pre-service review. Auricular Non Covered: Procedure/service not covered by the Plan. Not S8930 _ _ _ _ Electrostimulation subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 80/83 EIU: Procedure/service not reimbursed by the Plan. Not subject Hippotherapy Per S8940 to pre-service review. Check EIU policy CPCP028, which is one THE803.022 Hippotherapy _ _ Session of our Clinical Payment and Coding Policy (CPCP). Acne Management THE801.028 MP Criteria: Procedure/service reviewed against Medical Policy Acupuncture for Pain Management, Nausea and Vomiting and Low-Level Laser Trmt 15 SUR702.005 S8948 Criteria. Submit for predetermination to avoid post-service Opioid Dependence _ _ Min MED201.045 review. Low-Level and High-Power Laser Therapy MED205.022 Treatment of Tinnitus EIU: Procedure/service not reimbursed by the Plan. Not subject Home Uterine Monitor S9001 to pre-service review. Check EIU policy CPCP028, which is one OB401.017 Home Uterine Activity Monitoring _ _ With Or of our Clinical Payment and Coding Policy (CPCP). MP Criteria: Procedure/service reviewed against Medical Policy Procuren Or Other Recombinant and Autologous Platelet-Derived Growth Factors for S9055 Criteria. Submit for predetermination to avoid post-service RX501.034 _ _ Growth Fac Wound Healing and Other Non-Orthopedic Conditions review. EIU: Procedure/service not reimbursed by the Plan. Not subject Coma Stimulation Per S9056 to pre-service review. Check EIU policy CPCP028, which is one MED205.014 Sensory Stimulation for Coma Patients _ _ Diem of our Clinical Payment and Coding Policy (CPCP).

EIU: Procedure/service not reimbursed by the Plan. Not subject Vertebral Axial S9090 to pre-service review. Check EIU policy CPCP028, which is one THE803.021 Non-Surgical Spinal Decompression Traction Devices _ _ Decompressio of our Clinical Payment and Coding Policy (CPCP). Respite Care In The Non Covered: Procedure/service not covered by the Plan. Not S9125 _ _ _ _ Home P subject to pre-service review. Unlisted: Procedure/service not specifically defined or S9379 Hit Noc Per Diem _ _ _ _ classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not S9381 Hit High Risk/Escort _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9436 Lamaze Class _ _ _ _ subject to pre-service review. Childbirth Refresher Non Covered: Procedure/service not covered by the Plan. Not S9437 _ _ _ _ Class subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9438 Cesarean Birth Class _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9439 Vbac Class _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9442 Birthing Class _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9444 Parenting Class _ _ _ _ subject to pre-service review. Pt Education Noc Unlisted: Procedure/service not specifically defined or S9445 _ _ _ _ Individ classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not S9446 Pt Education Noc Group _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9447 Infant Safety Class _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9449 Weight Mgmt Class _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9451 Exercise Class _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9454 Stress Mgmt Class _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Cardiac Rehabilitation S9472 Criteria. Submit for predetermination to avoid post-service THE803.023 Cardiac Rehabilitation (CR) _ _ Progr review. Family Stabilization 15 Non Covered: Procedure/service not covered by the Plan. Not S9482 _ _ _ _ Min subject to pre-service review. Unlisted: Procedure/service not specifically defined or S9542 Ht Inj Noc Per Diem _ _ _ _ classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Ht Inj Growth Horm S9558 Criteria. Submit for predetermination to avoid post-service RX501.040 Human Growth Hormone (GH) _ _ Diem review. MP Criteria: Procedure/service reviewed against Medical Policy Gonadotropin-Releasing Hormone (GnRH) Agonists and S9560 Ht Inj Hormone Diem Criteria. Submit for predetermination to avoid post-service RX501.041 _ _ Antagonists review. Unlisted: Procedure/service not specifically defined or S9810 Ht Pharm Per Hour _ _ _ _ classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not S9900 Christian Sci Pract Visit _ _ _ _ subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Air Ambulanc S9960 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ Nonemerg Fixed review. MP Criteria: Procedure/service reviewed against Medical Policy Air Ambulan Nonemerg S9961 Criteria. Submit for predetermination to avoid post-service ADM1001.005 Ambulance and Medical Transport Services _ _ Rotary review. Health Club Non Covered: Procedure/service not covered by the Plan. Not S9970 _ _ _ _ Membership Yr subject to pre-service review. Transplant Related Per Non Covered: Procedure/service not covered by the Plan. Not S9975 _ _ _ _ Diem subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9976 Lodging Per Diem _ _ _ _ subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9977 Meals Per Diem _ _ _ _ subject to pre-service review. Med Record Copy Non Covered: Procedure/service not covered by the Plan. Not S9981 _ _ _ _ Admin subject to pre-service review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 81/83 Med Record Copy Per Non Covered: Procedure/service not covered by the Plan. Not S9982 _ _ _ _ Page subject to pre-service review. Not Medically Non Covered: Procedure/service not covered by the Plan. Not S9986 _ _ _ _ Necessary Svc subject to pre-service review. Serv Part Of Phase I Non Covered: Procedure/service not covered by the Plan. Not S9988 _ _ _ _ Trial subject to pre-service review. Services Provided As Non Covered: Procedure/service not covered by the Plan. Not S9990 _ _ _ _ Part Of subject to pre-service review. Services Provided As Non Covered: Procedure/service not covered by the Plan. Not S9991 _ _ _ _ Part Of subject to pre-service review. Transportation Costs To Non Covered: Procedure/service not covered by the Plan. Not S9992 _ _ _ _ And subject to pre-service review. Lodging Costs (E.G. Non Covered: Procedure/service not covered by the Plan. Not S9994 _ _ _ _ Hotel Ch subject to pre-service review. Meals For Clinical Trial Non Covered: Procedure/service not covered by the Plan. Not S9996 _ _ _ _ Par subject to pre-service review. Non Covered: Procedure/service not covered by the Plan. Not S9999 Sales Tax _ _ _ _ subject to pre-service review. Telehealth Transmit Non Covered: Procedure/service not covered by the Plan. Not T1014 _ _ _ _ Per Min subject to pre-service review. Elec Med Comp Dev Unlisted: Procedure/service not specifically defined or T1505 _ _ _ _ Noc classified, maybe subject to contract/clinical review. Noc Retail Items Unlisted: Procedure/service not specifically defined or T1999 _ _ _ _ Andsupplies classified, maybe subject to contract/clinical review. Habil Ed Waiver Per Unlisted: Procedure/service not specifically defined or T2012 _ _ _ _ Diem classified, maybe subject to contract/clinical review. Habil Ed Waiver Per Unlisted: Procedure/service not specifically defined or T2013 _ _ _ _ Hour classified, maybe subject to contract/clinical review. Habil Prevoc Waiver Unlisted: Procedure/service not specifically defined or T2014 _ _ _ _ Per D classified, maybe subject to contract/clinical review. Habil Prevoc Waiver Per Unlisted: Procedure/service not specifically defined or T2015 _ _ _ _ Hr classified, maybe subject to contract/clinical review. Habil Res Waiver Per Unlisted: Procedure/service not specifically defined or T2016 _ _ _ _ Diem classified, maybe subject to contract/clinical review. Habil Res Waiver 15 Unlisted: Procedure/service not specifically defined or T2017 _ _ _ _ Min classified, maybe subject to contract/clinical review. Habil Sup Empl Unlisted: Procedure/service not specifically defined or T2018 _ _ _ _ Waiver/Diem classified, maybe subject to contract/clinical review. Habil Sup Empl Waiver Unlisted: Procedure/service not specifically defined or T2019 _ _ _ _ 15Min classified, maybe subject to contract/clinical review. Day Habil Waiver Per Unlisted: Procedure/service not specifically defined or T2020 _ _ _ _ Diem classified, maybe subject to contract/clinical review. Day Habil Waiver Per 15 Unlisted: Procedure/service not specifically defined or T2021 _ _ _ _ Min classified, maybe subject to contract/clinical review. Serv Asmnt/Care Plan Unlisted: Procedure/service not specifically defined or T2024 _ _ _ _ Waiver classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or T2025 Waiver Service Nos _ _ _ _ classified, maybe subject to contract/clinical review. Special Childcare Unlisted: Procedure/service not specifically defined or T2026 _ _ _ _ Waiver/D classified, maybe subject to contract/clinical review. Spec Childcare Waiver Unlisted: Procedure/service not specifically defined or T2027 _ _ _ _ 15 Min classified, maybe subject to contract/clinical review. Special Supply Nos Unlisted: Procedure/service not specifically defined or T2028 _ _ _ _ Waiver classified, maybe subject to contract/clinical review. Special Med Equip Unlisted: Procedure/service not specifically defined or T2029 _ _ _ _ Noswaiver classified, maybe subject to contract/clinical review. Assist Living Unlisted: Procedure/service not specifically defined or T2030 _ _ _ _ Waiver/Month classified, maybe subject to contract/clinical review. Assist Living Unlisted: Procedure/service not specifically defined or T2031 _ _ _ _ Waiver/Diem classified, maybe subject to contract/clinical review. Res Care Nos Unlisted: Procedure/service not specifically defined or T2032 _ _ _ _ Waiver/Month classified, maybe subject to contract/clinical review. Res Nos Waiver Per Unlisted: Procedure/service not specifically defined or T2033 _ _ _ _ Diem classified, maybe subject to contract/clinical review. Crisis Interven Unlisted: Procedure/service not specifically defined or T2034 _ _ _ _ Waiver/Diem classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or T2035 Utility Services Waiver _ _ _ _ classified, maybe subject to contract/clinical review. Camp Overnite Unlisted: Procedure/service not specifically defined or T2036 _ _ _ _ Waiver/Session classified, maybe subject to contract/clinical review. Camp Day Unlisted: Procedure/service not specifically defined or T2037 _ _ _ _ Waiver/Session classified, maybe subject to contract/clinical review. Comm Trans Unlisted: Procedure/service not specifically defined or T2038 _ _ _ _ Waiver/Service classified, maybe subject to contract/clinical review. Vehicle Mod Unlisted: Procedure/service not specifically defined or T2039 _ _ _ _ Waiver/Service classified, maybe subject to contract/clinical review. Financial Mgt Unlisted: Procedure/service not specifically defined or T2040 _ _ _ _ Waiver/15Min classified, maybe subject to contract/clinical review. Support Broker Unlisted: Procedure/service not specifically defined or T2041 _ _ _ _ Waiver/15 Min classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or T5999 Supply Nos _ _ _ _ classified, maybe subject to contract/clinical review. Eyeglasses Delux Non Covered: Procedure/service not covered by the Plan. Not V2025 _ _ _ _ Frames subject to pre-service review. Lens Single Vision Not Unlisted: Procedure/service not specifically defined or V2199 _ _ _ _ Oth C classified, maybe subject to contract/clinical review.

Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 82/83 Contact Lens/Es Other Unlisted: Procedure/service not specifically defined or V2599 _ _ _ _ Type classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy V2627 Scleral Cover Shell Criteria. Submit for predetermination to avoid post-service DME104.003 Therapeutic Lenses, Scleral Shell _ _ review. Prosthetic Eye Other Unlisted: Procedure/service not specifically defined or V2629 _ _ _ _ Type classified, maybe subject to contract/clinical review. Non Covered: Procedure/service not covered by the Plan. Not V2702 Deluxe Lens Feature _ _ _ _ subject to pre-service review. Tint Photochromatic Non Covered: Procedure/service not covered by the Plan. Not V2744 _ _ _ _ Lens/Es subject to pre-service review. MP Criteria: Procedure/service reviewed against Medical Policy Presbyopia-Correct V2788 Criteria. Submit for predetermination to avoid post-service SUR713.025 Intraocular Lens (IOLs) and Implantable Miniature Telescope (IMT) _ _ Function review. Misc Vision Item Or Non Covered: Procedure/service not covered by the Plan. Not V2799 _ _ _ _ Service subject to pre-service review. Hearing Aid Dispensing Unlisted: Procedure/service not specifically defined or V5090 _ _ _ _ Fee classified, maybe subject to contract/clinical review. MP Criteria: Procedure/service reviewed against Medical Policy Implant Mid Ear V5095 Criteria. Submit for predetermination to avoid post-service SUR714.008 Semi-Implantable and Fully Implantable Middle Ear Hearing Aids _ _ Hearing Pros review. Hearing Aid Unlisted: Procedure/service not specifically defined or V5267 _ _ _ _ Sup/Access/Dev classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or V5274 Ald Unspecified _ _ _ _ classified, maybe subject to contract/clinical review. Ald Fm/Dm Receiver Unlisted: Procedure/service not specifically defined or V5287 _ _ _ _ Nos classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or V5298 Hearing Aid Noc _ _ _ _ classified, maybe subject to contract/clinical review. Unlisted: Procedure/service not specifically defined or V5299 Hearing Service _ _ _ _ classified, maybe subject to contract/clinical review.

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Updated August 2021 2021 Commercial _ Procedure Code List_BCBSIL 83/83